Consolidating and Sustaining Germ: In 2008, the family?s prior involvement with the agency and the consistent risk factors and chaotic lifestyle of the family was not adequately considered when simply offering Ms. M- voluntary services. There was sufficient demonstrated history that Ms. M-vould not engage in voluntary services and that A-would continue to be at risk. Provider The DCF Special Investigation review into death highlighted speci?c concerns regarding practices while L-was at the Mentor foster tome. - Mentor did not train foster parents on safe sleep environments, and the Mentor management team did not know what constituted a safe sleep environment. - Mentor did not adhere to its own policy of seeing a child within one week of placement. Reviewed 1) Commissioner An ele McClain 'L-s death at two months of age was reported as a ?Sudden UnexplainedDeath? while she was residing in a foster home. Though not a definitive causal factor, it was noted that L-Nas not put to bed in a safe sleeping.environment. There wereno egregious'D'CF casework practices related to L-?s death. This Family had along history with the Department prior to birth and the-parents had demonstrated limited parenting capacity, chronic homelessnessand substance - abuse Despite concerted efforts by social workers, the parents were not able to- successfully engage in treatment. It washighliglned during the Investigation into L.s death. that education-was needed tor staff and tester parents at Mentor. Inc. regarding safe sleeping arrangements for infants. The Deputy Commissioner for Field Operations and theAssistant Commissionertbr Foster Care,l_AdoIescent and Adoption Services are directedt'o wo'rk_ with Mentor to ensure-that this education is provided Signature Date Confidential [Page] Subject to Protective Order entered 6/17/2011 DCF011184867