San Luis Obispo County 2003-2004 - California Grand Jury Reports

June 10, 2004 — To the People of San Luis Obispo County This Final Report is presented to you by the 2003-2004 San Luis Obispo County

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Findings & Recommendations 9 findings

F1: "... a conflict of interest exists which would preclude the prosecution of the above-entitled matter by our office," 2) the "…case does not fit the strict traditional definition of a conflict of interest, but better judgment would indicate that an impartial review and prosecution of the case would be in the public interest due to the complex net of interactions that the fa- ther of the defendant has with members of our office," and 3) "We would appreciate it if your office would be kind enough to handle this matter to avoid any appearance of impropriety in the handling of this case by our office." The DA 's Office sent the file, containing only material related to this incident, to the AG after the AG agreed to take the case. The AG’s staff conducted their investigation, holding the case four months before determining that there were not sufficient grounds to file charges against the driver. We have incorporated in this summary the AG representatives' explanation to the GJ of some of their investigative process. On July 21, 2003 the AG met with the victim's family in SLO to apprise them of their decision to reject the case. Later that week the girl's mother called VW to request the DA re-review the case. Meanwhile the AG sent a letter to inform the DA of the decision. On August 19, 2003 the family and others came to meet with the DA and express their anger and frustration at the long delay of the filing decision. They also communicated their dissatisfaction with their lack of access to the Filing Deputy. The GJ received these same complaints in August. On September 3, 2003, two AG representatives came to the SLO County GJ Office. They stated this was a highly unusual action. They explained their decision to us and described what they did in reviewing the case. The AG does not consider the character, behavior, or prior infractions of a suspect unless it is relevant, or proves some fact, or is evidence that is usable to support a charge. They stated that they had reviewed the case in light of practices typically applied to cases reviewed in the Los Angeles urban area, where the number of such cases is greater. They file only the most provable cases with aggravated circumstances. They said that they did not consider the possibility of successful prosecution in a less populous county, despite the fact that workload considerations vary greatly between the two jurisdictions. On May 4, 2003 a Deputy AG personally visited the site of the incident and interviewed the GB Police officer who responded to the 911 call. The AG staff considered whether sufficient evidence existed for filing charges against the driver. They cited these factors in making their decision:

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R1: Children are, first and foremost, protected from abuse and neglect.

F2: the dark clothing worn by the victims

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R2: Children are maintained safely in their homes whenever possible and appropriate.

F3: conflicting evidence that both girls were within the crosswalk at the time the vehicle struck the girls

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R3: Children have permanency and stability in their living situations, without increasing reentry to foster care.

F4: that the driver’s speed was assumed to be within the posted speed limit, and

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R4: The family relationships and connections of the children served by CWS will be preserved as appropriate.

F5: no evidence that the driver had consumed alcohol. They examined the cell phone records of the driver for calls made on the evening of the incident and determined that he was not talking on his cell phone at the time that his vehicle struck the two girls. They believed that the two victims might have been outside the crosswalk at the time the vehicle struck the girls. Because of the focused involvement of the GJ, the AG investigator returned to SLO to re-examine evidence during the week of August 25-29. They nevertheless concluded that, in their opinion, the driver could not have avoided striking the victims. Listening to the AG's report, the GJ realized that the case file submitted to the AG by the DA's Office did not include the long list of the driver's prior driving citations and prior road rage convictions nor had they seen the accident photos. At the conclusion of the AG's presentation, the GJ's position was that the AG’s Office should reconsider its decision. The GJ asked the AG to review additional materials and provided them with accident photos and documents. The jury had compiled this supplemental information in its investigation of the matter. When the GJ apprised the AG representatives of these prior convictions, the AG staff responded that they could not use much of the driver’s prior traffic record because that information would not be admissible as evidence. The AGs agreed to take the box of materials from the GJ back to Los Angeles with them. The additional items, however, did not change the AG's opinion, and they so informed the GJ the next day. The AG notified the victim's mother again on September 4, 2003 that they were not prosecuting the case, but that the DA had the option of reclaiming the case. The victim's mother immediately called VW urging the DA to resume control and file charges against the driver. PART FOUR The District Attorney Reclaims the Case The Senior Assistant Attorney General informed the Chief Deputy DA in a letter dated July 23, 2003 that the AG staff’s review of the case was completed and that the AG’s Office decided not to file any criminal charges against the driver. The letter arrived to the desk of the Chief Deputy DA while he was out of the office on leave. Apparently no one was assigned to process his mail in his absence. He returned to work August 11 and immediately showed the letter to the DA. The Chief Deputy asked the AG to return the case paperwork to the SLO DA's Office. Meanwhile, after learning of the AG's original negative decision, the GJ wrote to the AG’s Office on August 15, 2003, just after receiving the family's complaints. The GJ wanted an explanation of the factors contributing to the AG's decision. The GJ advised the AG of the extensive local news coverage generated by the case and the hundreds of complaints the GJ had received. The AG decided to present an explanation to the GJ in person, something rarely done by that office. On September 3, 2003 two representatives of the Los Angeles division of the AG’s Office met with the GJ at the GJ office in San Luis Obispo to explain their decision of July 23. As explained in Part 3 of this report, the GJ disagreed with the AG Office’s decision and provided the AG representatives with additional information the GJ had compiled, including photos of the accident scene and information about prior offenses and convictions of the driver. However, that additional information apparently did not change the AG Office’s decision not to file charges. The day following that visit to the SLO GJ, the AG indicated their opinion had not changed despite the input from the GJ. On September 4, 2003 the attorney for the victim’s family sent a letter to the Chief Deputy DA stating that “It is our hope that… your office will now file the misdemeanor complaint against … and pursue prosecution in this matter.” On September 5, 2003 the Senior Assistant Attorney General sent a letter to the District Attorney forwarding more than 300 pages of material, including “…material you have not previously seen or requested.” She also referred information to the DA relating to a Department of Motor Vehicles administrative hearing decision to return the driver’s license and some information regarding the cell phone previously installed in the vehicle. None of that information proved to be relevant to this investigation. The AG indicated that the DA's Office was free to file if they chose to do so. That same day, September 5, 2003, the DA assigned the case to another Filing Deputy with the instruction to research and review the case and to recommend whether or not to file any charges. (Remember that on March 26 the Chief Deputy had instructed the filing deputy to "file the case.") Later that same day the DA’s Office filed one count of misdemeanor vehicular manslaughter against the driver. Case Status: The DA’s Office filed charges on September 5, 2003 in the San Luis Obispo County Superior Court and counsel for defense immediately proceeded to file a series of motions. In January 2004 a defense motion to recuse the DA’s Office from the case and effectively end the prosecution failed in superior court. Defense counsel had requested an April 2, 2004 hearing regarding his motion involving the prosecution’s failure to preserve the victim’s blood sample. Arroyo Grande Hospital did not keep the victim's blood drawn on the evening of the accident. The defense position is that the blood sample is potentially significant in the case because a preliminary screening by hospital staff had shown the presence of methamphetamine in the victim. The defense attorney, however, had a conflict on April 2, and the motion was continued to April 16. A ruling on all motions is necessary before the trial scheduling date of May 28. The SLO DA is ready to proceed with the trial, which has been set for June 22. AAAATTTTAAAASSSSCCCCAAAADDDDEEEERRRROOOO HHHHIIIIGGGGHHHH SSSSCCCCHHHHOOOOOOOOLLLL MMMMAAAARRRRCCCCHHHHIIIINNNNGGGG BBBBAAAANNNNDDDD PPPPLLLLAAAAYYYYSSSS AAAATTTT PPPPOOOOLLLLIIIITTTTIIIICCCCAAAALLLL CCCCAAAANNNNDDDDIIIIDDDDAAAATTTTEEEE’’’’SSSS CCCCAAAAMMMMPPPPAAAAIIIIGGGGNNNN RRRRAAAALLLLLLLLYYYY On Sunday, September 28, 2003 the Atascadero High School Marching Band played at a political rally for then candidate for governor, Arnold Schwarzenegger. To some county residents, this appeared to be in viola- tion of the California Education Code, which prohibits use of school resources for political purposes. Reports of the story in local newspapers included an opinion from the California Department of Education deputy legal counsel indicating that, if asked, he would have advised against the band playing. Within weeks of the event, the Grand Jury received two complaints from citizens citing this and other news reports, and express- ing concern that the Atascadero Unified School District had violated the law in permitting the band to play at the rally. Authority for the Inquiry The authority for the Grand Jury to inquire into this matter is given in Section 933.5 of the California Penal Code: “The grand jury may at any time examine the books and records of any special-purpose assessing or taxing district located wholly or partly in the county or the local agency formation commission in the county, and, in addition to any other inves- tigatory powers granted by this chapter, may investigate and report upon the method or system of performing the duties of such district or commission.” Overview The Atascadero Unified School District (AUSD) is responsible for the operation and su- pervision of thirteen schools, including Atascadero High School. The schools are located in the northern part of the county, serving the communities of Atascadero, Cres- ton and Santa Margarita. The district is governed by a Board of Trustees consisting of seven members who are publicly elected to four-year terms. The Board establishes the policies that govern the operations of the schools in the district, and hires the District Su- perintendent, who is responsible for policy implementation. Many of the Board policies reference the California Education Code, which sets the legal requirements for public schools in the state. The section of the code relevant to this in- quiry is 7054(a), which states: 17 No school district or community college district funds, services, supplies, or equipment shall be used for the purpose of urging the support or defeat of any ballot measure or candidate, including, but not limited to, any candidate for election to the governing board of the district. The applicable AUSD policy mirrors and references this section, and reads: No district funds, services, supplies or equipment shall be used to urge the support or defeat of any ballot measure or candidate, in- cluding any candidate for election to the Board. (Education Code

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R5: Children receive services adequate to their physical, emotional, and mental health needs.

F6: Children receive services appropriate to their educational needs.

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R6: Children receive services appropriate to their educational needs.

F7: Families have enhanced capacity to provide for their children’s needs.

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R7: Families have enhanced capacity to provide for their children’s needs.

F8: Youth emancipating from foster care are prepared to transition to adulthood. Source: The California Child Welfare Outcomes and Accountability System April 2003 (p. 12) 63 The first and overriding outcome is, “Children are, first and foremost, protected from abuse and neglect.” Our concern is that this primary goal may be compromised in the pursuit of achieving numbers used to measure progress toward other outcomes. The indicators the state is currently developing to assess whether outcomes are being met are typically meas- ured in terms of time and percentages, resulting in pressure to demonstrate specific out- comes within a pre-defined time frame. The push to achieve the statistical goals for the sec- ond, third, and fourth outcomes underlies the repeated recommendations for reunification and placement with relatives noted in the cases reviewed in the Placement section of this report. The statistical accountability inherent in the Redesign is new to most social services. The requirement that future state and federal financial support will be tied to achieving per- formance goals is an even more significant change for local welfare agencies. As an organizational entity, San Luis Obispo CWS has developed a positive relationship with the state. In 1998 it was chosen as a “pilot county” for testing the effectiveness of Best Practices. According to DSS Director Leland Collins, he was the only county director in- cluded in the state’s development of a response to the federal government’s review of the child welfare system. The most recent positive recognition from the state was the selection of the local CWS as an early implementer of the Redesign. This brings $2.85 million of addi- tional funding through 2007, and also brings pressure to implement new programs and to meet the statistical goals in the many categories defined in the AB 636 framework. The CWS Deputy Director is often required to be in Sacramento working with state CWS staff. Besides accommodating the demands of federal and state changes, DSS/CWS upper man- agement must explain and defend budget shortfalls to the county. Additional pressure on CWS derives from commitments associated with special funding that they have received. Grants. Several of the CWS initiatives have been implemented with grants that bring addi- tional funding to the county. Current grant projects include Linkages and Family to Family. The Linkages grant provides a total of $45,000 over a 13-month period, ending in November 2004, to facilitate a partnership approach between CWS and other services available to its clients. The goal includes a new organizational structure to support a “one door model” of social services in Atascadero. Family to Family is a three-year grant designed to integrate principles associated with reforming the foster care system. The grant provides $100,000 for the third year, which ends in October 2004. CWS management publicly presents grant funding as adding resources for helping children and families at no additional cost. There are, however, “hidden costs” to such grants that may exceed the value added, as several of our interviewees highlighted. These costs in- clude accounting and reporting requirements that require staff time. An analysis provided to the Grand Jury estimated the CWS financial cost of grants to be 20 percent of the grant value. The greater cost may be the refocus and reorientation of social workers’ most valuable re- source, time. For example, compliance with the Linkages grant required reorganization and office relocations, adding expense and stress at a time when social work resources were already stretched. The Family to Family grant requires increased efforts to recruit foster families and to document an average of 40 “Team Decision Meetings” per month. Pressures for grant compliance define such activities and meetings as social worker priorities. The es- 64 timate provided to us was that 20 to 25 percent of CWS social worker time has been redi- rected to grant compliance activities in recent years. County budget. A state DSS funding source that California counties have come to depend on is a time-lagged reimbursement for money spent over and above their state allocations. Referred to as “overmatch,” this reimbursement has not been available during the state’s recent budget shortfalls. As a result, San Luis Obispo County had to increase its funding for CWS programs during the 2003-2004 fiscal year, and will likely have to adjust the county share upward in coming years. The local DSS anticipated these budget cuts and instituted a voluntary hiring freeze in May 2002. The Board of Supervisors made the hiring freeze mandatory in November 2003. When the DSS director explained the CWS budget shortfall to the Board in January 2004, he also requested authorization to further reduce CWS by 18.5 positions and eliminate all temporary positions. This request was approved. Apparently, there are no plans to use any of the $2.85 million the county will receive under the early implementer Redesign grant to add social workers or staff. As we noted previously, placement decisions have financial consequences that are reflected in the CWS budget. In the DSS budget, the single largest item is for Foster Care and Adop- tions Assistance. CWS can keep the county share of the DSS budget down by using lower cost foster care and adoption placements. The state mandated CWS placement priorities tend to be inversely related to the costs associated with them. For example, the preferred goal of reunification with family is typically the least expensive, while placement in a group home is the least preferred and one of the most expensive options. Foster care for special needs children, e.g., those with developmental disabilities, can become very expensive for the state and the county, especially when the children are placed in homes that are ap- proved to provide special services. Money has also become a source of distrust within CWS, especially in this time of scarce resources and financial pressures. Many employees whom we interviewed and who are be- ing asked to do more with less, question upper management decisions that are perceived as costly. While special grants add to social worker workloads, they do not fund additional hu- man resources. The complexity of DSS, and particularly CWS funding, renders it difficult to understand. Nei- ther DSS nor the CWS division, however, has had an independent financial audit in at least ten years. The DSS financial manager, a member of the executive team, disagreed with up- per management on several financial analyses. His position was eliminated by the Board of Supervisors in January 2004, upon the recommendation of the DSS Director. Within this context of change and financial pressure, tensions between upper management and CWS employees are increasing. In the next section, we discuss some of the issues surrounding the CWS/CMS data collection tool, because these issues capture many of the dynamics of this strained relationship. We will then focus on the management style and the work environment at CWS. CWS/CMS The Child Welfare Services Case Management System (CWS/CMS) is an online reporting system that the state now requires all CWS agencies to use. Locally, CWS has been work- ing toward integrating the system for several years, during which time employees have been required to learn not only computer skills but also new ways of completing work. The system is now being used to gather data at the state level and to monitor CWS social worker performance at the local level. As part of the Redesign and AB 636, the state will use the information to track the county’s success in meeting the established benchmarks. Suc- cess at achieving statistically defined goals will determine state funding allocations in the future. As a tool for gathering data, the system will likely increase both the speed and accuracy of reporting information to the state and federal levels. When fully operational, the system will eliminate the need for the local office to devote time and resources to accumulating and pre- paring separate reports to state and federal agencies. This is an effective use of technology for the social services. The CWS/CMS capability also has significant implications for how work is performed and evaluated at the local CWS office. With the CWS/CMS in place, the focus of social workers’ evaluations has become whether they have entered case notes and reports into the computer system on time. When asked how social worker performance is measured, CWS managers responded by explaining how the CWS/CMS allows them to monitor social worker reports and case note entries. Our con- cern is that the value of social workers is shifting from how effective they have been in work- ing with a family or protecting a child toward how proficient they have become in entering data into a computer. The management argument is that they should be able to do both – that documenting what they do has always been a part of social workers’ jobs. For new social workers trained during the years since computers have been integrated into most professions, using the new technologies should be reasonably straightforward. For some seasoned social workers, however, computerized notes and reporting require signifi- cant change. The danger is that valuable experience and expertise in working with children and families will be lost if the primary evaluation criteria for social workers becomes that which can be tracked on a computer. The concerns expressed to us indicate that CWS/CMS is being used as a weapon to intimidate and eliminate social workers whose per- formance, which is now being measured by timely computer input, is not up to standards. In our interviews, we were told about two ways in which CWS/CMS can be, and has been, used at CWS to undermine social workers. The first relates to management’s ability to monitor individual cases and social worker input on the system. Managers explained that supervisors can use this information to identify areas where social workers need assistance. However, some social workers expressed concern that it is also being used for managers to seek detailed information about the work of individuals who they see as being uncoopera- tive. Management then pressures supervisors to initiate progressive discipline against those social workers. A second potential for abuse of the CWS/CMS is that it allows supervisors and managers to change information a social worker inputs to a case note or report for the court. This is par- ticularly problematic in the context of state pressures for specific outcomes where local CWS funding may depend on this information. Changing the information in CWS/CMS is a con- cern that may be solved by technology. However, this is symptomatic of a larger problem – that the distrust at CWS is so intense that social workers suspect their managers of such behavior. Management Style A repeated theme in our interviews with CWS employees was that upper management either is unwilling or unable to communicate with employees on a professional level. This does not fit the image of a professional organization in which information and practice is freely ex- changed and discussed. Social workers are professionals by definition and required qualifi- cations, and their job descriptions include significant responsibilities and judgments. Com- munication is central to their work, and they expect to be able to work in a professional set- ting. The barriers to communication at CWS are both upward and downward. Our interviewees reported that efforts to express concerns regarding local implementation of state mandates are routinely told that, if they don’t like it, they can work somewhere else. They described an atmosphere where questioning is seen as opposition rather than an opportunity for dialogue, and an environment that precludes discussing changes or suggesting alternative ap- proaches. The message they receive is that employee input is neither sought nor wel- comed. Downward communication was described as dictatorial. We were told that decisions are made at upper levels and decreed as final, on simple procedures as well as fundamental social work practice and resources. An example of the disconnect between management and employees became clear in our discussions of the new procedural Desk Guides. The managers we interviewed told us that Desk Guides were being developed with the input from all social workers who would be affected by them. The social workers we interviewed, how- ever, told us the Desk Guides were coming to them fully written, with no opportunity for input or discussion. This heavy-handed management style has also been applied to decisions about social work resources, such as group homes, and even discussion of a professionally accepted diagnosis. Resource decision. Group homes, a resource considered by many social workers to be a critical placement option for children in the CWS system, were in effect eliminated in San Luis Obispo County. This appeared to some to be a unilateral decision to appeal to state standards. Group homes are identified as the most restrictive (i.e., the least desirable) in placement pri- orities because they are believed to lack the individual nurturing environment of families. They are also among the most expensive placements. Multiple children can be placed in group homes that are operated by paid staff, many of whom are professionals in the human services. While a general perception of group homes is one of a mini-institution, social work- ers indicated to us that these placements may be the most appropriate for some children 67 who are better able to function within the clearly defined structure of a group home. This is most often true for older and/or emotionally disturbed children. Such children can be ex- tremely disruptive, and at times dangerous, in family settings. Nevertheless, in recent years Best Practices, and now federal and state standards, have dis- couraged group home placements. In response, local group homes were for a time removed as a resource. The result left CWS social workers without appropriate local placement op- tions for some children. Instead, they were left with either placing children in foster homes against their better judgment, or sending them out of county, and even out of state. This lat- ter option is expensive, separates the child from most family support systems, and requires extensive social worker travel time and money to comply with the monthly visit requirements. Diagnosis discussion. A psychiatric diagnosis that is applied to some children in the CWS system is Reactive Attachment Disorder of Infancy or Early Childhood (RAD). It is a recog- nized diagnosis by the American Psychiatric Association and defined in its Diagnostic and Statistical Manual of Mental Disorders. RAD is associated with failure of a child to bond with a caregiver early in life, and is characterized by “markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years.” 6 Among the methods used to treat children diagnosed with RAD, one was the subject of a recent public controversy. Coincidental with the national publicity about this treatment, local CWS management took the extraordinary measure of attempting to ban discussion or mention of the legitimate diag- nosis of RAD. Social workers told us that even written material mentioning RAD was re- moved from CWS reference sources. In the spring of 2003, the main presenter at a profes- sional conference in Morro Bay was a therapist whose expertise included RAD. The DSS Director urged the sponsoring agency to cancel the conference and, failing that, refused to authorize any DSS staff to attend. CWS Workers and the Work Environment We heard from several sources that the work environment at CWS is not supportive of the social workers who most directly deliver services to children and families. Our sources in- cluded current and former CWS employees as well as professional employees of other agencies who work with CWS. While our interviewees emphasized the competence and dedication of many of the front line social workers, they noted that even the best employees were being stressed by a tense atmosphere often punctuated with intimidation by CWS management. The CWS employees we interviewed dated the start of their dissatisfaction at about the time the current DSS Director was hired (August 2000), which was the same time the Deputy Di- rector for CWS was appointed. This timing was also identified by other agency profession- als. The image that emerged from our interviews and documentation is of a divided agency, with CWS management aligned against a significant number of social workers. As with the individuals who appealed to the Grand Jury out of their frustration in dealing with CWS on placement cases, current and former CWS employees contacted us after their ef- forts to address the issues directly with management were ineffective. Attempts to resolve 68 the problems had included individual efforts to discuss concerns with management, and an appeal to the Deputy Director in a letter signed by CWS social workers in 2002. The re- ported response to the letter was a verbal lashing by the Deputy Director at a meeting, and no improvement in communication. In April 2003, the San Luis Obispo County Employees’ Association (SLOCEA) began a con- certed effort to work on the problems at DSS. Approximately 76 percent of the then- employed permanent CWS social workers signed a SLOCEA supported petition that re- sulted in a June 2003 meeting with the DSS Director and 130 DSS employees. The em- ployee concerns presented at this meeting were categorized as: accountability of managers to employees, lack of leadership on the part of managers, fear and intimidation in the work- place, and unmanageable workloads. The director’s response was to communicate by e- mail, addressing each area of concern. As of the filing of this report, employees had re- ceived e-mails from the director on three of the four topics, but had not received one dis- cussing the issue of workloads. According to a SLOCEA survey conducted in the fall 2003, the problems at DSS continued with little change. The workload of social workers at CWS is of particular concern, because the safety and wel- fare of children is at stake. There are several issues involved, making it difficult to reduce simply to a question of caseload size. In fact, the DSS/CWS management response to con- cerns about caseloads is that they are within range of state averages. Social worker responsibilities at CWS, in addition to working with families and children, in- clude participation in committees and meetings associated with various grant initiatives and Redesign implementation. The hiring freeze and staff reductions have further strained the resources. Social workers and supervisors on various types of leave are no longer replaced, and existing workers are expected to cover their cases during their absence. Employees reported several instances in which social workers have been required to assume responsi- bilities beyond their qualifications, job classification, and salary. At least one social worker cited a heavy workload as the primary contributor to inappropriate decisions affecting chil- dren’s welfare. Many others expressed concern that such decisions were inevitable in the current environment. To support administrative requirements, some social workers have been assigned to non- case-carrying positions. Recent reorganizations have resulted in supervisors not familiar with the work or the employees they are responsible for managing. Office and records relo- cations have added to the adjustments needed to accomplish basic tasks. Increased scru- tiny of reports and case notes through the CWS/CMS has added pressures for timely docu- mentation. Management has increased the use of formal documentation necessary to initi- ate the progressive discipline process, leaving employees in fear of losing their jobs. Our interviewees also expressed concerns about the lack of relevant and professional train- ing provided to CWS employees. Training sessions are offered for procedural matters such as orientation to new Desk Guides, but are not available for discussing the implications of new policies or thinking through their implementation. There is training for new social work- ers offered through the state’s Core Academy, and an orientation to county policies, but there are no training periods or programs for social workers and supervisors who are trans- ferred to new units or given additional responsibilities. There is little continuing education in 69 social work practices available through the department. When the professional conference referenced earlier was held in Morro Bay, CWS employees were not permitted to attend. Many of the experienced social workers we interviewed acknowledged that scarce resources and work overload are part of a normal cycle in social services. They had been through a number of such cycles over the course of their careers and understand that periods of belt- tightening are to be expected. What distinguishes the current situation to them is that the sense of support and unity to help them through the difficult phase is missing. Instead, it has been replaced by a managerial harshness and indifference to employees’ concerns. The current work environment at CWS is not conducive to meeting the considerable chal- lenges facing the organization. The state has warned local CWS agencies about the funda- mental changes inherent in implementing the Redesign. California DSS-published docu- ments outline not only the positive potential but also acknowledge the difficulty of the transi- tion processes. The Child Welfare Redesign Final Report (September 2003) highlights the need for effective leadership in implementing the fundamental changes, and the change in the organizational culture that will be required in many local agencies. It is this Grand Jury’s assessment that the San Luis Obispo CWS does not have the demonstrated leadership re- quired to bring about these drastic changes. Findings Management style/communication (1) The CWS upper management’s autocratic leadership and communication style in- crease the inherent job stress of social workers. (2) Key decisions affecting social work resources and practice are made unilaterally from the top, with little discussion or input from those who must implement these decisions. (3) Communication at CWS is top down only, is not open to employee input, and is not appropriate for professional employees such as social workers. Upper management is neither accessible nor visible to many social workers. (4) CWS upper management efforts have been directed more toward the state, county and grant funding sources than toward creating an open, supportive, and coopera- tive work environment. (5) Upper management has demonstrated that they are unwilling to engage in pro- fessional dialogue with employees. (6) Distrust exists between social workers and upper management at CWS. (7) The climate at CWS has led to social workers’ anxiety that they may be fired without prior notice or placed on administrative leave without explanation. 70 (8) The decision to remove local group homes as a placement option for children in the CWS system has resulted in additional travel, time, and expense. (9) CWS upper management blocked access to information and discussion of a recog- nized psychiatric diagnosis. Additionally, CWS workers were not authorized to at- tend a professional conference because it may have included discussion of this di- agnosis. (10) CWS employee efforts to formally communicate problems were not accepted by the CWS Deputy Director. CWS employee attempts to communicate concerns with the DSS Director have not resulted in meaningful change. Workload (11) The unrecognized costs to grants received by CWS increase administrative and social worker responsibilities. (12) Special initiatives and grants redirect social worker efforts toward compliance activi- ties and have the effect of adding work without adding resources to social workers. CWS grant money is not used to add social worker positions. (13) The Redesign implementation adds meetings and other tasks to the workload of so- cial workers. (14) The cumulative effect of the DSS hiring freeze, the elimination of permanent and temporary positions, and not filling in for social workers on leave, has resulted in in- creased workloads of social workers and supervisors. (15) With the current workload requirements, it is unrealistic for social workers to be ex- pected to complete their work within the hours of a normal work week. (16) Some CWS social workers are working above their job classification. (17) No social worker job analysis has been conducted to reflect the current technology and the work requirements under the Redesign. Training (18) Newly-hired CWS social workers are not given adequate time for caseload and pro- cedures orientation. (19) Neither relevant training nor transition time is provided for CWS employees when they are reassigned to new work units or positions. (20) Relevant training and continuing professional education for CWS social workers is limited. 71 (21) There is no provision for training social workers or managers for: a) the culture change required by the Redesign, and b) team dynamics to support the demands of CWS requirements for teamwork. CWS/CMS (22) The CWS/CMS can be an efficient and effective application of technology for pur- poses of case reporting and documenting, and for identifying areas where there is need for improvement in caseload management. (23) Social worker notes and reports can be, and are, monitored by supervisors and man- agement using the CWS/CMS. (24) The potential for abuse of CWS/CMS includes supervisors and managers changing social worker notes and reports, and upper management’s scrutiny of social worker inputs to find cause for disciplinary actions. (25) The CWS/CMS tracking capacity is being used to measure social worker perform- ance in terms of reports, case notes and documentation entered into the system rather than evaluating social worker effectiveness in working with children and fami- lies. Financial issues (26) Financial decisions have become a source of distrust within CWS. (27) DSS/CWS has not had an independent financial audit in at least ten years. (28) The county share of the 2003-2004 DSS budget was amended upward to make up for the failure of the state to reimburse for “overmatch” expenditures. DSS/CWS is under pressure to reduce its costs so as not to increase further the county share of its budget. (29) Placing children in lower cost placements is one way to keep down the county share of the DSS budget.

Related Recommendations (1)

R8: Youth emancipating from foster care are prepared to transition to adulthood. Source: The California Child Welfare Outcomes and Accountability System April 2003 (p. 12) 63 The first and overriding outcome is, “Children are, first and foremost, protected from abuse and neglect.” Our concern is that this primary goal may be compromised in the pursuit of achieving numbers used to measure progress toward other outcomes. The indicators the state is currently developing to assess whether outcomes are being met are typically meas- ured in terms of time and percentages, resulting in pressure to demonstrate specific out- comes within a pre-defined time frame. The push to achieve the statistical goals for the sec- ond, third, and fourth outcomes underlies the repeated recommendations for reunification and placement with relatives noted in the cases reviewed in the Placement section of this report. The statistical accountability inherent in the Redesign is new to most social services. The requirement that future state and federal financial support will be tied to achieving per- formance goals is an even more significant change for local welfare agencies. As an organizational entity, San Luis Obispo CWS has developed a positive relationship with the state. In 1998 it was chosen as a “pilot county” for testing the effectiveness of Best Practices. According to DSS Director Leland Collins, he was the only county director in- cluded in the state’s development of a response to the federal government’s review of the child welfare system. The most recent positive recognition from the state was the selection of the local CWS as an early implementer of the Redesign. This brings $2.85 million of addi- tional funding through 2007, and also brings pressure to implement new programs and to meet the statistical goals in the many categories defined in the AB 636 framework. The CWS Deputy Director is often required to be in Sacramento working with state CWS staff. Besides accommodating the demands of federal and state changes, DSS/CWS upper man- agement must explain and defend budget shortfalls to the county. Additional pressure on CWS derives from commitments associated with special funding that they have received. Grants. Several of the CWS initiatives have been implemented with grants that bring addi- tional funding to the county. Current grant projects include Linkages and Family to Family. The Linkages grant provides a total of $45,000 over a 13-month period, ending in November 2004, to facilitate a partnership approach between CWS and other services available to its clients. The goal includes a new organizational structure to support a “one door model” of social services in Atascadero. Family to Family is a three-year grant designed to integrate principles associated with reforming the foster care system. The grant provides $100,000 for the third year, which ends in October 2004. CWS management publicly presents grant funding as adding resources for helping children and families at no additional cost. There are, however, “hidden costs” to such grants that may exceed the value added, as several of our interviewees highlighted. These costs in- clude accounting and reporting requirements that require staff time. An analysis provided to the Grand Jury estimated the CWS financial cost of grants to be 20 percent of the grant value. The greater cost may be the refocus and reorientation of social workers’ most valuable re- source, time. For example, compliance with the Linkages grant required reorganization and office relocations, adding expense and stress at a time when social work resources were already stretched. The Family to Family grant requires increased efforts to recruit foster families and to document an average of 40 “Team Decision Meetings” per month. Pressures for grant compliance define such activities and meetings as social worker priorities. The es- 64 timate provided to us was that 20 to 25 percent of CWS social worker time has been redi- rected to grant compliance activities in recent years. County budget. A state DSS funding source that California counties have come to depend on is a time-lagged reimbursement for money spent over and above their state allocations. Referred to as “overmatch,” this reimbursement has not been available during the state’s recent budget shortfalls. As a result, San Luis Obispo County had to increase its funding for CWS programs during the 2003-2004 fiscal year, and will likely have to adjust the county share upward in coming years. The local DSS anticipated these budget cuts and instituted a voluntary hiring freeze in May

F2003: The family sought to motivate action because the impending September 11, 2003 expiration of the statute of limitation would prevent any subsequent criminal prosecution. Authority The Grand Jury exercises its authority to investigate the San Luis Obispo County District Attorney under Penal Code 925, which states "The grand jury shall investigate and report on the operations, accounts, and records of the officers, departments or functions of the county" and for the Grover Beach Police Department under Penal Code 925a, which authorizes the investigation of city departments. The last two parts of this report are informational only, and are included to help the reader make the bridge between the case leaving, then returning to the county. Background A traffic accident occurred in Grover Beach that resulted in the death of a 17-year-old girl. Typically, in a case of a traffic accident resulting in a fatality, the law enforcement agency of the local jurisdiction where the accident occurred conducts a comprehensive investigation of the accident scene, the vehicle, and any persons who were involved or witnessed the event. After assessing the information compiled, the local agency then forwards its report, along with any recommended charges, to the County District Attorney's (DA) Office for review of the file, any necessary additional investigation, and a decision whether or not to file charges against any participants. If the DA's Office feels that charges are appropriate and a reasonable chance exists to sustain the charges, the DA will file the determined charges with the appropriate court of law. The DA is elected by the voters of the county to a four-year term to lead the county's prosecuting agency. Due to the volume of misdemeanor and felony cases forwarded to the DA's Office by local law enforcement agencies each year, the DA employs a staff of deputy DAs to assist with review and prosecution of cases. Among these are a chief deputy who serves to oversee the deputies; a filing deputy responsible for case review and filing of the less serious, or misdemeanor cases; and a filing deputy for the more serious felony cases. The filing deputies must make the decision whether or not to file charges before the statute of limitation expires. Once it expires, the opportunity to prosecute ends, regardless of the merit of the charges or the ability to successfully prosecute the case. When the filing of a case involving injury or death occurs, the Victim Witness (VW) Division of the DA's Office is notified. VW then assigns a staff advocate to provide assistance and support to the victim and/or family throughout the process of prosecution. When a valid or perceived conflict of interest exists, the DA's Office may request a review by the Attorney General's (AG) Office. The AG's Office also employs a staff of deputies and assistants to handle the review and prosecution of cases. If, in the opinion of the AG's staff attorneys, sufficient grounds exist to file charges and a reasonable chance for prosecution exists, the AG's Office will file charges in an appropriate court. Generally, if the AG's Office determines that grounds are insufficient, the case is closed and the matter ends. Method of Investigation The Grand Jury requested, in some cases subpoenaed, copies of the police file, the driver's previous driving history, his court and probation records, and his insurance claim pertaining to this accident. Some of the documents gathered for the investigation include the District Attorney's Protocol Addressing Conflict of Interest and Case Management and Complaint Filing Procedures. In addition we obtained Victim Witness notes, various correspondence, attendance sheets, and workload records for the Misdemeanor Filing Deputy District Attorney (Filing Deputy). The Jury also examined minutes of the Pension Trust Fund meetings for the past five years, Pension Trust Fund travel and expense vouchers for that Filing Deputy and the Tax Collector who is the father of the driver involved in the accident. We then reviewed the above materials, which precipitated our need to question individuals on several matters. The jury conducted interviews with police officers from the Grover Beach and Pismo Beach departments who responded to the accident. We interviewed many District Attorney personnel to learn what actually transpired in the District Attorney's Office after the police report was submitted. We questioned the intake secretary, the Filing Deputy, the Chief Deputy District Attorney, three other deputy district attorneys, the information technology lead programmer, and three victim witness advocates including the Victim Witness Director who had talked with the family. In all interviews conducted, the GJ placed the witnesses under oath and admonished them not to discuss the proceedings with anyone else. At least nine jurors were present at each interview, and the proceed- ings were tape recorded for later reference and review by the jurors who were not able to attend. Some of these interviews were transcribed by one of the jurors for clarification of the facts. Members of the Grand Jury visited the location of the accident at night, observed the scene, the lighting, and even crossed the street using the same crosswalk. Later, two deputies from the Attorney General's Office came to our Grand Jury Office to present their reasons for declining to file charges against the driver. We developed this report for the public after reviewing the information extracted from a myriad of sources. We have organized the data chronologically within each section as much as possible. The investigative Parts 1 and 2 detail the events by numerical order. The informational sections, Parts 3 and 4, use the narrative form. Acronyms will be used throughout the report for convenience. The following table of acronyms will help the reader. Acronyms Used AG California Attorney General AGH Arroyo Grande Hospital DA San Luis Co. District Attorney GB Grover Beach GBPD Grover Beach Police Dept GJ San Luis Co. Grand Jury MAIT Calif. Highway Patrol's Multidisciplinary Accident Investigation Team PB Pismo Beach SLO San Luis Obispo VW Victim Witness Part One: Grover Beach Police Department (GBPD)'s accident investigation Part Two: San Luis Obispo County District Attorney (DA)'s Office processing and Victim Witness (VW) handling of the case A) Communication within DA staff and filing conflicts: What went on in the DA's Office? B) Case remains in the DA's Office for six months without a decision to file or reject: How could "shelving" of the file go unnoticed for six months? C) Victim Witness involvement: How could the VW Office better assist the family? Part Three: Transfer of the case to the California Attorney General (AG) Office Part Four: The District Attorney reclaims the case. AG Office relinquishes the case to the SLO DA Office and DA files the charge of vehicular manslaughter without gross negligence. PART ONE Grover Beach Police Department Investigates Facts: (1) Two teenage female pedestrians were crossing Grand Avenue northbound at 5th Street in Grover Beach at 9:04 p.m. on Saturday, September 7, 2002. (2) A 1997 Chevrolet Tahoe was traveling west on Grand Avenue at the same time. (3) The vehicle struck the pedestrians, causing serious injuries that resulted in the subsequent death of one girl and minor injury to the other. (4) GBPD responded to the emergency call. Findings: (1) The GB police officer on patrol at the time arrived within two minutes of the accident. (2) The San Luis Obispo Ambulance Service was requested at 9:06 p.m., arriving at 9:10, to provide medical attention and to transport the seriously injured victim to Arroyo Grande Hospital (AGH). A second ambulance, summoned at 9:12 p.m., arrived at 9:17, took the other victim to AGH where she was treated and re- leased. (3) The GB responding officer interviewed and took statements from five witnesses at the site of the accident. (4) The GB officer interviewed the driver and administered a preliminary alcohol breath test, then released him. (5) When another GB police officer came on duty, that officer went to the driver’s home, and at 10:11 p.m., took him to AGH to obtain a blood sample. (6) Neither the first-responding GB police officer, nor his watch commander on duty at the time of the accident, had the training required to issue a citation at the scene of the accident unless he had witnessed the accident. (7) A Pismo Beach police officer with advanced traffic accident training arrived at 9:57 p.m. and assisted with the investigation, as requested by GB police. (8) The GB police officer's report did not indicate any adverse weather or lighting conditions as contributing causes of the accident. (9) The police report showed no tire skid marks on the pavement. 5 (10) The GBPD impounded the vehicle and arranged for a full inspection. (11) The GB officer and a police volunteer took photos that night, and later, during the accident reconstruction. (12) On September 10, 2002, the GBPD requested that California Highway Patrol Multidisciplinary Accident Investigation Team (MAIT) inspect the vehicle. MAIT inspected the vehicle on September 12, 2002. (13) MAIT's vehicle inspection ruled out malfunction as a cause of the accident. (14) September 11, 2002, four days after the accident, the seriously injured victim died from the injuries she had sustained. (15) On September 24, 2002, the GBPD submitted a complete report in triplicate - including accident details, photos, medical reports, and witness statements - to the SLO County DA Office. (16) The GB police accident report recommended that the DA review the report for possible prosecution of the driver for violation of Penal Code Section 192(C), ve- hicular manslaughter without gross negligence, and Vehicle Code Section 21950(a), pedestrian right of way at a crosswalk. (17) After submitting its report to the DA's Office, GBPD considered its task complete. Per the department’s standard operating procedure, police personnel did not make any further inquiries about the case or the possible prosecution of the driver. Conclusions: (1) The GBPD conducted a thorough investigation of the accident. (2) Accident reconstruction efforts followed guidelines detailed in the Collision Investigation Manual. (3) Weather, lighting, and vehicular malfunction were ruled out as causative factors. (4) GBPD insured that the appropriate medical reports were included in the investi- gation package before delivery to the DA. (5) The initial responding officers were unable to write a citation at the scene because they lacked the requisite training. (6) GBPD processed the case efficiently and effectively. (7) GBPD's delivery of the complete report to the DA’s office was timely. Recommendations: (1) The GBPD should make every reasonable effort to train additional field personnel so that citations may be written at the scene, when appropriate. (2) In future cases involving death or serious injury, the GBPD should routinely follow up and inquire of the DA as to the status of the case. GBPD Response Requirement Under Penal Code Section 933(c), the governing body of the GBPD shall comment to the presiding judge on these findings and recommendations no later than 90 days from this report's publication. PART TWO District Attorney's Office Processing and Victim Witness Handling of the Case A. What went on in the District Attorney's Office? Facts: (1) The DA's receptionist received the file from the GBPD on September 24, 2002 and date-stamped it. (2) The Intake Secretary personally delivered the large file to the Deputy DA responsible for misdemeanor filings after numbering and processing the file. (3) No system was in place at that time for tracking misdemeanor cases. (4) The file remained in the Filing Deputy's office from late September 2002 until March 26, 2003. (5) The Filing Deputy did not contact GB or PB police officers about their accident investigation, or call upon the DA investigators to conduct additional investiga- tion. (6) The Filing Deputy stated to the GJ that he did not discuss with his colleagues his problem with filing. (7) The District Attorney received a letter from the victim's mother on March 18, 2003, questioning the delay in filing charges. (8) On March 26, 2003, the Chief Deputy DA told the filing deputy to file the case. 7 (9) The Filing Deputy said he could not file the case because he could not find a violation of the vehicle code. (10) This same Filing Deputy filed serious criminal charges against this same driver in 1999 which resulted in a conviction. (11) The Filing Deputy told the GJ that in reviewing the file in March 2003, he discovered that the driver is the son of the County Tax Collector whom he knows. The Filing Deputy serves with the County Tax Collector on the County Pension Trust Fund board, which poses a possible appearance of conflict of interest. (12) Upon learning that the County Tax Collector is the driver's father, the Chief Deputy took the file for transfer to the AG's Office on March 26, 2003 to avoid any perception of conflict of interest. Findings: (1) The Filing Deputy had opportunity to examine the file in late September 2002. (2) The file remained in the Filing Deputy's office for six months without the knowledge of senior DA personnel due, in part, to the lack of a tracking system. (3) The Filing Deputy did not act on the case, to either file or decline to file, during the six months the case remained on his desk. (4) He did not seek advice of the Chief Deputy DA or the DA after he read the file. (5) He did not discuss with other DAs, before March 26, 2003, any perceived problem about filing. (6) Each time the victim's mother requested to speak to him he declined. He chose to communicate through the victim's family’s attorney. (7) The Chief Deputy, on March 26, 2003, directed the Filing Deputy by saying, "You need to file this case." It was then that the Filing Deputy said he first noticed a document from the tax collector's office bearing the name of the driver's father. (8) The Chief Deputy, acting on this possible conflict, contacted the AG Office in Los Angeles, asking that office to review the file. (9) The Senior Assistant AG stated that the case did not meet the usual parameters of conflict, but would take it as a courtesy. (10) GJ investigation of Pension Trust Fund minutes of January 26, 1998 through July 28, 2003, travel vouchers, conference expenses, and Auditor/Controller records of the past five years did not expose any connections that suggested a conflict 8 between the Filing Deputy and the County Tax Collector, despite their serving on that same committee. Conclusions: (1) The Filing Deputy did not act to perform his duty to file or reject this case. (2) The Filing Deputy withdrew from any of the alternative actions available to him. (3) The Filing Deputy, when questioned by the Grand Jury, had no acceptable explanation for his inaction. (4) The lack of a tracking system for misdemeanors allowed this case to go unresolved and unnoticed for six months. (5) The Chief Deputy DA accepted the perception of a conflict of interest and referred the case to the AG. (6) The District Attorney's Office did not file or reject the case in March 2003, causing additional extended stress to the victim's family. (7) Because of this case, in April 2003, the Chief Deputy DA requested two new systems of tracking. One was to track the more serious high misdemeanor (red dot) pending cases; the more recent one, for pending cases neither filed nor re- jected. (8) This case fueled the formulation of a new procedure (still in draft in the DA's Office) titled Filing Procedures for Vehicular Manslaughter Cases (and Other Cases Involving a Fatality). (9) The Grand Jury found nothing to indicate to us that a conflict of interest existed with the DA handling the case, in the interviews we conducted or the records we reviewed. (10) The Grand Jury’s initial observation was that the Filing Deputy’s performance in the handling of this case should be sanctioned. However, a closer examination revealed that management personnel either knew, or should have known, that a review of this fatal accident was pending. News articles, for example, were printed at the time of the accident in local newspapers in which the driver was named. News articles in December 2002 identified the driver as the son of the County Tax Collector.