By Karen Ocamb

A preliminary report from the Office of Independent Review (OIR) investigating the conduct of Los Angeles Department of Children and Family Services in the case of 2-year-old Sarah Chavez concluded that six to eight DCFS personnel "are potentially accountable as a result of action or non-action" leading up to her death last October. The coroner ruled that Sarah died from blunt force trauma to her stomach that completely severed her small intestine. Sarah's great aunt and uncle have been charged with her murder.

The 12-page report submitted to the L.A. County Board of Supervisors on Dec. 15 was redacted and released to the media on Jan. 27 at the behest of DCFS Director Dr. David Sanders. The report details stunning ineptitude and systematic failures on the part of those charged with protecting the toddler, starting Dec. 7, 2002, two days after Sarah's birth. A social worker at White Memorial Medical Center called the child abuse hotline to report that newborn Sarah and her mother, Sophia Chavez, had tested positive for Vicodin, a prescription pain medication, the report says. The next day an emergency response caseworker (ER CSW) interviewed Sophia who said that her dentist had given her a prescription after a tooth extraction, but she couldn't remember any information about the dentist. She also told the caseworker that she was "unaware that she was pregnant until she started feeling pain and was taken to the hospital." The case was turned over to another ER CSW for follow-up.

"Needless to say, it was important to verify that the mother had a prescription because of the suspicious nature of the mother's story," the report says which "indicated that she may have knowingly abused an addictive controlled substance while pregnant." However, either the follow-up never occurred or it was not documented, which "raise serious questions" about the caseworker's credibility or his adherence to DCFS policy.

Court documents and testimony in the preliminary hearing for the murder trial of Francis and Armando Abundis, Sarah's relatives, indicate that Sarah lived with the Abundises "on and off" until DCFS next became involved on Jan. 1, 2005, when Sophia gave birth to a stillborn in the toilet. Court documents indicated the baby had Vicodin in its system. A hospital nurse called the child abuse hotline to report that Sarah could be a possible victim of abuse or neglect. A Los Angeles police officer responded to the Abundis home in Alhambra and took Sarah into protective custody. The investigating ER CSW noted that Sarah had two black eyes and a half-inch cut on the bridge of her nose, but only asked Sophia about the injuries -- not Francis Abundis, with whom Sarah was living. The ER CSW later said she regarded the injuries as "suspicious."

DCFS policy requires that the ER CSW immediately should have created an "Allegation Notebook" to document all allegations and investigations of child abuse, immediately reported the allegation to the Child Protective Hotline, and taken Sarah for a comprehensive forensic examination known as a suspected child abuse and neglect exam (SCAN), mandatory for suspected victims under age 5 within 72 hours of the suspicion or evidence. The ER CSW failed in every instance.

The case handling case worker who received Sarah's case on Jan. 6 also failed to take Sarah for the SCAN exam, even though, the OIR report says, the case worker should have "recognized that Sarah's unusual behavior -- sexual, aggressive, and self-injurious -- was also a sign of possible physical abuse, and constituted subsequent impendent grounds to obtain a SCAN exam."

The case worker's notes from Feb. 11 indicate that foster parents Corri Planck and Diane Hardy-Garcia repeatedly requested a SCAN exam, reporting concerns about the toddler's behavior, which included nightmares, getting angry, trying to choke them, yelling, "Fuck you," and putting a water bottle in her vagina in the bathtub. The caseworker finally scheduled a SCAN exam but it was for three days after Sarah was abruptly and inexplicably removed in April from the foster parents' home and returned to Francis Abundis, who never took her to the exam.

The OIR report is replete with other DCFS-related failures that "paint a continuing picture of a child who was possibly being subjected to ongoing abuse in the Abundis home." The OIR also raises questions about how personnel at Garfield Medical Center and those in the Juvenile Courts handled Sarah's case.

"It was incredibly painful to read about the level of abuse she endured, and that there were so many opportunities for a different outcome," Planck told IN Los Angeles magazine. "Sarah's case was bungled from the time of her birth and continued until her death. It's just more confirmation of our worst fears. The whole situation continues to break our hearts."

Planck and Hardy-Garcia have formally requested that the district attorney convene a grand jury. "While the OIR report documents the failures of the Department of Children and Family Services, it doesn't address the entire systemic breakdown that ultimately led to Sarah's death, including the legal and health care systems," Planck says. "The criminal trial will take its course, but we believe there are also systemic failures that must be investigated, made public and addressed."

DCFS' Sanders, who has thoroughly cooperated with the on-going OIR investigation, told IN that there are several concerns that can be addressed within the department "to make sure they don't happen again." One is to ensure that if a child appears to have injuries, they immediately receive an exam and assessment from medical experts. "We can't wait," he said. "That's so contrary to what we're about as an organization." Sanders said he is also looking at ways for the medical experts and the caseworkers to directly enter information into the system "from the field" so it is immediately available. He also wants any child that goes out of home placement to be immediately seen by trained county hospital staff for an initial assessment.

"I want to wait for the final report, but when I look at the [OIR], it does not appear that an effort was made to make sure [a SCAN] happened," Sanders said. "That's contrary to policy and a huge problem. We can't assure children's safety if we can't assure they're getting appropriate medical care." Another point is the need to play a strong advocacy role in court. "There are reasonable questions about whether we did that or not," he said.

Sanders said the Board of Supervisors has consistently been clear that they expect the persons responsible for the errors to be held accountable. He is also working on a recommendation to forge a "permanent agreement" with the OIR and, to the extent possible within the law, have information shared publicly.

Supervisor Zev Yaroslavsky told IN that he is "very supportive of a recommendation that involved OIR or some mechanism that provides oversight and transparency that an issue like this deserved and deserves."

Michael Gennaco, OIR Chief Attorney, told IN he also supports such a recommendation. Additionally, he said that investigators "will do our best" to gather the facts and "look at how the ultimate decision was made to take Sarah from her foster parents and return her to a family member."

Gennaco expects the final OIR report to be completed in late February.