FEDEH 51?5 Ell STATE OF AND HUMAN SERVICES AGENCY DEPARTMENT OF SOCIAL SERVICES T44 Street - Sacramento, CA 95814 modsscagov WILL EDMUND a. snow? JR. DIRECTOR sovesmon February 16, 2016 Mr. Elliott Robinson, Director Monterey County Department of Social and Employment Services 1000 S. Main Street, Suite ?301 Salinas, CA 93901 Dear Mr. Robinson: The. California Department of Social Services (CDSS) is the single state agency responsible for the administration and supervision of the Child Welfare Services system, providing oversight to county child welfare agencies that administer direct services to children and families. In the event of a child fatality or near fatality, referred to as a "critical incident", CDSS may conduct a' specialized review to identify systemic issues, and areas of statewide policy and local practice that if changed may reduce or prevent the occurrence of future critical incidents. Due to the nature of the critical incident, and at the request of Monterey County Department of Social and Employment Services (MCDSES), CDSS conducted a critical incident review during January 2016. The three-day review included a detailed case file review of the critical incident, review of 24 selected referral and case files, and interviews with MCDSES staff and supervisors. The report findings enclosed highlight the need for MCDSES to strengthen its intake and assessment practices, a process that MCDSES has already initiated. We appreciate the cooperation offered MCDSES during the review, and look fonivard to continued partnership between MCDSES and CD88 to strengthen county practice. For further information, you may contact me at (916) 657-2514. puty Director FEB 23 2016 Children and Family Services Division . COUNTY Enclosures SOCIAL SERVICES OFFICE FEDEH 5175 PSEE EIE Monterey County Department of Social 8; Employment Services (MCDSES) 2015 Critical Incident Findings Recommendations Introduction As the single state agency responsible for the administration and supervision of the Child Welfare Services (CWS) system, the California Department of Social Services (CD38) is charged with providing oversight to county child welfare agencies that administer direct services to children and families. The CDSS performs various oversight activities to ensure that services protect children, strengthen families and are focused on safety, permanency and well-being. In the event of a child fatality or near fatality, referred to as a ?critical incident," CDSS may conduct a specialized review to identify systemic issues and areas of statewide policy and local practice that, if changed, may reduce or prevent the occurrence of future critical incidents. This report provides a summary of ?ndings of the critical incident involving three children based upon the review conducted by CD83 staff in Monterey County. Key findings outlined in this report are focused on the safety of children and require immediate attention and correction by Monterey County. Additional recommendations offered are consistent with current best practices and may be incorporated by the county during its efforts to improve existing policies and practice. An internal review conducted by MCDSES following the critical incident has identified similar ?ndings. In response, MCDSES has initiated system changes to expand front- end resources including, redirection of experienced staff to the intake unit and a request to the Monterey County Board of Supervisors for additional staff. Background On December 15, 2015, CDSS learned of the fatalities of a seven year old male and three year old female resulting from abuse and neglect and the associated near fatality of a nine year old female- The two deceased children were found in Shasta County following a welfare check conducted by Plumas County, in which the surviving nine year old half~sibling was found and taken into protective custody. All three children had a Child Protective Services (CPS) history in Monterey County. Due to the nature of the critical incident and at the request of Monterey County, CDSS staff conducted a site visit to understand the specifics around the critical incident and evaluate what areas MCDSES may need technical assistance to strengthen county child welfare practices- Prior to the site visit, CDSS staff reviewed information regarding the critical incident and the chronology of events obtained from the Child Welfare Sewicelease Management System (CWSICMS), SafeMeasures?, and Structured Decision Making (SDM) tools. In addition, CDSS staff reviewed a sample of 24 referrals and emergency response (ER) cases from Monterey County with similar characteristics to the critical incident to assess general practices regarding intake, assessment and investigation. Page 1 8232432818 18:58 FEDEH DFFICE 5125 83 Monterey County Department of Social Employment Services (MCDSES) 2015 Critical Incident Findings :5 Recommendations On January 4, 2015, (3835 staff from the Children's Services Operations and Evaluation Branch began a three-day review including a detailed case ?le review of the critical incident and review of the 24 selected referral and ER case files with similar characteristics. During their visit, CDSS staff conducted interviews with six intake staff and supervisors, three emergency response staff and supervisors and the program manager. During the course of the visit, a number of areas for strengthening county child welfare practices were identified. Monterey County Child Welfare Services Structure and Outcomes?Data According to the MCDSES, Family and Children?s Services Organizational Structure document dated January 6, 2015, Family and Children?s Services has one deputy director, four program development/quality outcomes staff, two program managers, and 13 staff units, each of which are managed by one supervisor. One program manager oversees the intakefhotline unit; two emergency response units; the Family Stabilization/Pathways to Safety differential response unit; the clerical unit; the quality assurance, licensing and interstate Compact on the Placement of Children unit; and the team meeting facilitators unit- Another program manager oversees the court unit; two family reunification units; one adoptions unit; and one permanent placement unit. The intakelhotline unit receives calls from Monterey County?s child abuse and neglect hotline and determines whether calls are information and referral only or promoted to a referral and assigned for investigation or evaluated?out for community services. The ER units conduct investigations of child abuse and neglect allegations, determine the outcome of the allegations (unfounded, inconclusive or substantiated), and ensure children are safe through the provision of ER services, development of safety plans and, if necessary, removal of children from the care of their parents/guardians. Pathways to Safety is the MCDSES differential response program which provides alternative responses to calls that come into the CPS hotline. Through Pathways to Safety, families who have come to the attention of the MCDSES but whose referral is determined not to meet the legal definition for abuse and neglect are connected with community resources to address the underlying causes that may have triggered the call to CPS. Pathways to Safety services are provided by non?profit social service It: or referral: llrerl. em: evaluate-wool, l'errnilirso elite directly referred to and contacted by a Pathways to Safety family resource specialist under a Path 1 response. For'referrals assigned a 10-day child welfare response, a family resource specialist and a MCDSES social worker will jointly visit the family. Under this Path 2 response, the social worker and family resource specialist work together to determine if either a) child safety issues exist which require a traditional child welfare response or b) only nonwchild safety issues are present and a family resource specialist can respond to the families? needs. When referrals are assigned an immediate 24-hour child welfare response, a traditional child welfare response is conducted by MCDSES as a Path 3 response. Page 2 8232432815 18:58 FEDEH OFFICE 5125 PAGE Elsi Monterey County Department of Social 8-. Employment Services (MCDSES) 2015 Critical Incident Findings 8; Recommendations Currently, MCDS ES uses statistical data analysis software such as, Statistical Analysis System (SAS), Structured Query Language (SOL), and Business Objects to collect, monitor and analyze quantitative child welfare data to understand trends and opportunities for improvement within the MCDSES child welfare system. The Efforts to Outcomes system is used to capture and analyze Pathways to Safety differential response data, including program effectiveness. Additionally, MCDSES was an early implementer of the state-mandated CW3 Qualitative Case Review, in which a standardized instrument is used to assess a variety of performance areas on specific cases. The MCDSES also conducts additional internal qualitative case reviews and participates in various continuous quality improvement activities. Monterey County outcomes data is tracked in various areas using SafeMeasuresCE). According to SafeMeasures?, as of January 30, 2016, there were 451 open investigations, 12 emergency response cases, 105 family maintenance cases, 125 family reuni?cation cases, 260 permanent placement cases, and 30 supportive transition cases in Monterey County. In the ER (investigations) units, seven social workers had 30 or more open investigations while seven social workers had fewer than 30 open investigations (per worker). In the intakefscreener unit, all six social workers had fewer than 20 open referrals. The following outcomes measures are limited in this report to those relating to child safety. For a complete list of publicly available California child welfare data and their methodologies, please visit the California Child Welfare Indicators Project (CCWIP) website at Regarding Recurrence of Maltreatment, of the children in Monterey County with a substantiated allegation between October 1,2013, and September 30, 2014, 8.3 percent of children experience a subsequent substantiated allegation within 12 months of the initial substantiated allegation. The national standard for this measure is to be below 9.1 percent. Monterey County has met or exceeded the national standard in this measure for seven out of the most recent 12 reporting periods.?I Regarding Maltreatment in Foster Care, for the October 1, 2014 September 30, 2015 reporting period, Monterey County's performance was 0-79 incidents of maltreatment in foster care per 100,000 days in foster care. The national standard for this measure is to be below 3.5 incidents of maltreatment in foster care per 100,000 days in foster care. Monterey County has met or exceeded the national standard in this measure for 12 out of the most recent 12 reporting periods.1 1 Webster, 0., Armijo, M, Lee, S., Dawson, W., Magruder. J., Exel, M., Cuccaro?Aiamin, S.,.Putnam- Hornstein, E., King. EL, Rezvani, (3., Wagstaff, it, Sandoval, A., Yes, H., Xiong, E5, Benton, C., Hoerl, C, Romero, R. (2016). CCWIP reports. Retrieved 1131/2016. from University of California at Berkeley California Child Welfare Indicators Project website. URL: Page I 3 ElEr?E?ir?EEllEr FEDEH 51?5 PAGE EIE Monterey County Department of Social 8r Employment Services (MCDSES) 2015 Critical Incident Findings Recommendations Regarding Timer Immediate Response Investigations, during the July 1, 2015 September 30, 2015 reporting period, on 93.6 percent of referrals assigned as immediate response, investigations were initiated timely within 24 hours. The national standard for this measure is to be above 90 percent. Monterey County has met or exceeded the national standard in this measure for 11 out of the most recent 12 reporting periods.1 Regarding Timely 10?Day Response investigations, during the July 1, 2015 September 30, 2015 reporting period, on 93.1 percent of referrals assigned as 10?day response, investigations were initiated timely within 10 days. The national standard. for this measure is to be above 90 percent. Monterey County has met or exceeded the national standard in this measure for 12 out of the most recent 12 reporting periods.1 Regarding Timely Social Worker Visits with children in out of home care, during the October 1, 2014 September 30, 2015 reporting period, 97.? percent of required visits were made within the required month.- The national standard for this measure is to be above 95 percent. Monterey County has met or exceeded the national standard in this measure for 12 out of the most recent 12 reporting periodsfI Of the 97.7 percent of visits made during the October 1, 2014 - September 30, 2015 reporting period, 88 percent occurred in the residence where the child was placed in out?of?home care. The national standard for this measure is to be above 50 percent. Monterey County has met or exceeded the national standard in this measure for 12 out of the most recent 12 reporting periods.1 Monterey County has invested heavin in prevention and early intervention services to address child maltreatment in its earliest stages. As a result, Monterey County has lower than average rates of recurrence of alleged maltreatment. Data from families utilizing differential response demonstrates reduced rates of substantiated recurrence of maltreatment- When children enter foster care, Monterey County achieves a high level of placement stability demonstrating that the county provides supportive services to ensure few moves for children who have experienced abuse or neglect. Monterey County foster youth avail themselves of resources under Assembly Bill 12 such as the Transitional Housing Plus Program. Monterey County incorporates the perspective of youth in its Transition Age Youth Program design through close relationships with the local chapter of California Youth Connection and the Epicenter, a locally established youth resource center. Critical Incident Review and Findings The CDSS review of the critical incident included examination of prior CPS referrals within Monterey County, and the intake, screening and investigation of these referrals. The CDSS staff relied upon review of CWSICMS documentation, available hardcopy referral documentation and interviews with the assigned social workers, social work Page 4 FEDEH 5175 EIE- Monterey County Department of Social a Employment Services 2015 Critical Incident Findings 3; Recommendations supervisors and the program manager. The generated five2 referrals involving the three children and aunt in the critical incident. In addition, MCDSES received a suspected child abuse report (SCAR) which was not opened or investigated as a new referral- The MCDSES con-ducted investigations of four referrals and made two attempts to connect the family to community services and resources through its Pathways to Safety Program before losing contact with the family. During review of the intake and investigation activities involving these referrals, CDSS identi?ed five areas where MCDSES must strengthen its child welfare practices to fully comply with state regulations set forth in the Manual of Policies and Procedures (MPP), and four areas that could be strengthened to reflect best practice. 1) The MPP section 31?101 requires the county to respond to all referrals that allege a child is endangered by abuse, neglect or exploitation. The social worker shall respond by either by completing an ER protocol or conducting an in-person investigation either immediately or within 10 days. a. During the course of the onsite review at MCDSES, CD33 staff identified a SCAR containing information about a child involved in the critical incident that was not opened as a referral within the database. Instead, CD88 staff observed that the SCAR had been entered into the county?s Information and Referral (INR) log because it was reportedly mistaken as a duplicate to a previously investigated referral. As a result, the SCAR was not weighed in any investigation or responded to by MCDSES. The CDSS staff shared this finding with who immediately initiated a full review of the INR system and processes. 2) The MPP section 31-105 requires the social worker to immediately initiate an ER protocol to determine whether an in?person visit is needed. a. In one referral, the ER protocol was not completed immediately, but was entered into the CWSICMS system six days after the referral was received. CDSS staff observed that the protocol was incomplete based upon information provided by the reporting party. This referral was evaluated out. b. An ER protocol was not completed immediately following receipt of the SCAR, as this report was not opened as a new child abuse/neglect referral. 2 Two referrals were opened on the same date based on similar reports. The responded to both referrals in one investigation. Page 5 FEDEH 5175 El? Monterey County Department of Social Employment Services (MCDSES) 2015 Critical Incident Findings 3: Recommendations 3) The MPP section 31-1302 prohibits using law enforcement assistance as a substitute for completion of the-ER protocol or performance of the in?person investigation. a. The CD38 review identified that in one referral, MCDSES did not immediately complete the ER protocol or conduct an innperson investigation, but instead relied upon information provided by law enforcement who conducted a welfare check. 4) The MPP section 31-125 requires social workers investigating a referral to determine the potential for or the existence of any conditions which place a child, or any other child in the family or household, at risk and in need of services. a. The CDSS review found that in one referral, one child disclosed physical abuse to themselves and another child that was not documented in as an additional allegation- Although documentation showed the allegation was discussed with the aunt, it did not demonstrate further action was taken such as interviewing the alleged perpetrator, creating a safety plan or conducting further investigation. b. In another referral, MCDSES gathered information that a child was left with the caregiver by a non-biological parent who may not have had legal authority to do so. The CD53 staff did not observe documentation that this was further investigated by MCDSES since law enforcement conducted the health and welfare check at the request of MCDSES. The social workers did confirm with another county child welfare agency that guardianship would be addressed. in a later referral, I MCDSES provided relatives with a referral to establish legal guardianship. 5) The MPP section 31-1015 requires a county to determine whether child welfare services are necessary or close the referralfcase within 30 days of the in?person investigation. The purpose of the 30 day timeframe is to ensure that investigations of child abuse and neglect, and needed services, are provided timely. a. The CD88 review found that two referrals were open longer than 100 days and remained open at the time of the children's deaths. Although one of the investigations had been completed within the 30 day timeframe, the administrative closure of both referrals was not completed within the required timeframe. Page 6 FEDEH 5175 EIE Montwey County Department of Social 8: Employment Services (MCDSES) 2015 Critical Incident Findings Bi Recommendations 6) When questions of legal custody arise during an investigation, best practice is to observe documentation confirming the caregiver has legal custody of a child and the individual leaving the child in their care had appropriate authority to do so. a. The CDSS review identified that in every referral MCDSES did not verify or observe the notarized document of consent to care for the children which the aunt reported she had. 7) Best practice is to'verify the whereabouts of all alleged victims and to physically observe them if present during an in?person contact. a- The GDSS review found that in one referral, there was no physical observation of any of the alleged victims at the initial contact. The aunt indicated one child was sick. There was no documentation of the location of the other two child victims at the initial contact. 8) Best practice is to conduct a body check of each child when physical abuse has been indicated. a. The CD33 review found that in one referral, a body check was not documented as having been performed for each child when physical abuse was alleged or disclosed by the children. In a second referral, body checks were performed for two children but not for the child alleged to be physically abused due to a stomach ache. Although the social worker I attempted later in?person contacts with the. child alleged to be physically abused, the family was evasive, preventing the social workers physical evaluation. 9) Although not a violation of state regulations, the proper use of SDM as the ER protocol requires the completion of SDM safety and risk assessments, and preparation of safety plans for safety assessment with a ?nal assessment of ?safe with plan? and ?unsafe.? a- In three referrals, the SDM hotline tool was not completed as required. In two referrals, SDM safety and risk assessments were not completed within the required timeframes, and in one referral, the SDM safety and risk assessments were completed based on incomplete information about conditions of the home. Case Review Findings Recommendations Intake and Screening In the course of their review, CDSS staff observed a number of practices related to the intake screening process that do not conform to California state regulations set forth in Division 31 of the MPP or recognized best practice. The intake screening process is a critical step in assessing a child?s risk of abuse and or neglect. When a call is received at the child abuse hotline, the screener must complete an ER protocol to determine Page 1 18:58 FEDEH DFFICE SITE BE Monterey County Department of Social Er Employment Services (MCDSES) 2015 Critical Incident Findings 8: Recommendations whether the call can be safely evaluated out without an investigation or if an investigation should be completed and how quickly the investigation should be initiated. All of these decisions must be documented within the CWSICMS and the associated assessment system, SDM. This section provides a summary of regulatory compliance and best practice findings related to the 24 referrals and ER cases reviewed by CD35. Findings: 1) State regulations at MPP section 31-101 .1 require that, ?The county shall respond to all referrals for service which allege that a child is endangered by abuse, neglect or exploitation.? The MPP section 101.3 further requires, "The social worker shall respond to a referral by completing an ER protocol or conducting an in-person investigation immediately or within 10 days." The CD33 staff observed, through a preliminary review of the county?s INR logs for a three-month time period and in five cut of 10 interviews, that the ER protocol is inconsistently used for calls alleging child abuse and neglect from non?mandated reporters. Rather, the intake social worker may check to see if there is information in the database to support the claim and make a note. Furthermore, the decision to enter a call as INR, rather than complete the ER protocol, is not staffed with or reviewed by a supervisor to ensure decisions are consistent and appropriate. Due to time constraints, (3085 staff were not able to conduct a full review onsite of all INR legs at however, CD555 staff observed calls which were entered as INR, but alleged child abuse and neglect should have been opened as referrals into the CWSICMS and received the necessary response required by state regulations. The CD88 staff shared their initial observations with staff who immediately initiated a full review of the INR system and processes. The CDSS staff reviewed INR statistics for Monterey County compared to California state averages and the averages of comparable surrounding counties. While the typical county both statewide and in the Central Coast uses INR for less than one percent of hotline calls, Monterey County utilized the INR procedure on 20.6 percent of hotline calls in 2015. Full review is necessary to determine if these calls were appropriately entered as lNRs. The MCDSES has adopted SDM as the ER protocol for Monterey County. Proper use of SDM as the ER protocol within MCDSES requires that the SDM hotline tool be completed immediately upon receipt of a call alleging child abuse or neglect. The CD53 found that in eight of the 24 referrals and cases reviewed. the hotline tool was not completed immediately as required. Page E2324HEEIE FEDEH OFFICE 51?5 1s Monterey County Department of Social ii; Employment Services (MCDSES) 2015 Critical Incident Findings 8.. Recommendations Recommendations: 1) The MCDSES should ensure that its policies, procedures and practices involving 2) 3) 4) the use of INR are consistent with state regulations requiring response to a referral of child abuse or neglect. All reports of suspected abuse and/or neglect must be opened as a referral in CWSICMS and assessed through the ER protocol, unless the social worker has already determined an ianerson investigation is required. All intake decisions, including those determined by the intake social worker, to meet INR criteria should be reviewed by a supervisor to ensure calls concerning child welfare are appropriately screened, assessed for safety and risk and documented in the database. The MCDSES should continue its full review of the INR system and processes. The MCDSES should ensure policies, procedures and practice concerning the completion of the SDM hotline tool are consistent with the SDM Policies and Procedures Manual (PPM). Comprehensive Investigations Once an intake social worker has determined that the allegations of abuse or neglect warrant an in?person investigation, the ER social worker must conduct an initial in- person investigation immediately or within 10 days, depending on the immediacy of risk to the child. Findings: 1) The MPP section 31425222 requires the county to, ?make necessary collateral contacts with persons who have knowledge of the condition of the children." The CD88 staff found that in five out of 24 referrals and ER cases reviewed by CD35, Monterey County underutilized collateral contacts. During four out of 10 interviews conducted with MCDSES staff, when a supervisor required a collateral contact to be made prior to the closure of a case, common practice in the county would be to call the child?s school for attendance records, which does not substantively meet the requirement of making contact with an individual who has ?knowledge of the condition of the child.? The CD33 found that in nine of the 24 referrals and cases reviewed, Monterey County staff only conducted in person investigations with children who were mentioned in the allegation. The county may elect not to interview other children in the home, who are not present during the initial in-person investigation, pursuant to MPP section 31-12523. However, this practice potentially causes key pieces of information to be missed that would aid the investigation and determination process. Page I 9 EEHE4HEEIE FEDEH OFFICE 51?5 ll Monterey County Department of Social 8; Employment Services (MCDSES) 3) 2015 Critical Incident Findings 8; Recommendations In two of the 24 referrals and cases reviewed, the social worker did not verify who had legal custody of the children involved. Best practice indicates that if there is a question as to who has legal custody of the children, the social worker should verify that the caretaker has the legal custody or make contact with the legal guardian to confirm the caretaker has been given care of the children. In 22 of the 24 referrals and cases reviewed, CD88 observed that although intake workers provided a summary of previous child welfare history, CD88 did not observe documentation that investigative staff independently reviewed the family?s prior CW8 history before conducting the initial in~person investigation, which is inconsistent with best practice. The State of California, in an effort to ensure all counties have the best tools possible to ensure child safety, has an agreement to provide 8DM, a comprehensive and evidence-based set of child welfare assessment tools to those counties that choose to use it. Currently, 54 out of 58 California counties, including Monterey County use 8DM- The other four counties utilize a county? supported safety and risk assessment tool. Counties electing to utilize 8DM are expected to use it in accordance with its "Em. a. The 8DM requires that social workers complete a safety assessment within two working days of initial face-to-face contact with all child victims, and complete a risk assessment within 30 days. Safety and risk assessment tools aid a social worker in identifying whether a child can safely remain in their home. The risk and safety assessment must be completed when the social worker has reached a conclusion regarding the allegation and prior to the decision to promote to a case or close without continuing services. Based upon CD88 analysis of 8afeMeasures? data, threenquarters of 8DM safety assessments in Monterey County were . completed more than two working days after initial face?to-face contact. The CD88 foLind that in 17 of the 24 referralsand cases reviewed, the SDM safety assessment was not completed within the required timeframe. The risk assessment was not completed within the required timeframe in nine of the 24 referrals and cases reviewed. Recommendations: 1) 2) The MCDSES should ensure policies, procedures and practice are consistent with state regulations for investigations, including interviews with children and collateral contacts. The MCDSES should strengthen policies, procedures and practice around verification of legal custody for children involved in an abuse or neglect referral when there is a question of who has legal custody. Page 10 FEDEH OFFICE 51?5 12 Monterey County Department of Social Employment Services (MCDSES) 2015 Critical Incident Findings 8: Recommendations 3) The MCDSES should ensure that investigations are thoroughly documented in the CWSICMS. 4) The MCDSES should strengthen policies, procedures and practice around the review of prior child welfare history documentation in the CWSICMS database prior to- meeting with the family. 5) The MCDSES should ensure policies, protocols and practice around the required timing for completion of SDM safety and risk assessments are consistent with the SDM PPM. 6) The MCDSES should consider implementing a quality assurance process to ensure accurate use of SDM assessment tools. 7) The MCDSES management and staff expressed barriers to completing comprehensive investigations when families were evasive or resistant to interview and MCDSES could not access children. Although MCDSES is able to interview children in exigent circumstances, MCDSES should consider amending policies for interviewing children at school to allow social workers better opportunities to access and obtain crucial information from children outside of the home. The CDSS observed that MCDSES requires parents to sign a release form when exigency cannot be established before children could be interviewed, resulting in cases where parents refused access to their children and impeded a thorough investigation. Due to competing concerns involving a family?s constitutional rights, such policies should be reevaluated and any amendments developed in close consultation with County Counsel. Additionally, CD53 has seen that counties with a process for obtaining protective custody and general warrants report fewer barriers to interviewing resistant or evasive families. The MCDSES does not have an established process for protective custody and general warrants, and should work with the courts to establish such processes. Intervention If it has been determined that a child is living in a situation that poses a threat to his or her health andior safety, the social worker must determine if the child can be maintained safely at home. if possible, the social worker may utilize a safety plan. A safety plan should be a written document, signed by the parent(s), with specific, measureable actions that the parents will take to ensure their children can remain safely at home. Findings: 1) The SDM PPM (pg. 53) specifies that each county should use their own safety plan form and outlines additional items to be included in a safety plan. The (3033 found that in five of the 24 referrals and cases reviewed, safety plans were verbal rather than written, did not follow a consistent format, did not provide a detailed description of the safety threat and proposed intervention, did not identify who would be participating in the plan and the role of each participant. Page 11 FEDEH SITE PHASE 13 Monterey County Department of Social 8; Employment Services (MCDSES) 2015 Critical Incident Findings Recommendations 2) The SDM PPM (pg. 54) specifies that safety plans should be developed in partnership with and agreed to by the family. The CD83 observed in the same five referrals and cases mentioned above, a safety plan was put in place but was not signed by family members, the social worker or social work supervisor. 3) The SDM PPM (pg. 36) specifies that that a safety plan should be created whenever a threat to the child?s wellbeing has been identified on the assessment, regardless of whether the child will remain home or be placed in care. The CDSS observed that in three of the 24 referrals and cases reviewed, written safety plans were only created for placement moves. 4) The SDM PPM (pg. 49) specifies that when a safety plan is initiated, there must be an updated safety assessment documenting that the safety threat has been resolved. The CD33 observed in that in five of the 24 referrals and cases reviewed, an updated safety assessment was not completed. Recommendations: 1) The MCDSES should develop a safety plan document or form to aid the social worker in designing a safety plan with the family. This document should be consistently used, signed by the family, worker and supervisor and cepies appropriately maintained and documented. 2) Safety plans should be documented in the database. 3) The MCDSES should ensure that safety plan policies, procedures and practices incorporate the requirement to create safety plans that are SMART (specific, measurable, assignable, realistic and time-related) and specify appropriate follow-up for a family with a safety plan. Action Steps This report has outlined both key findings that have immediate impacts on child safety, as well as areas that while important, may be addressed as part of a longer term strategy of system improvement. Based upon review of the critical incident, referrals and cases reviewed, CDSS has identified the intake and screening process discussed in this report as an area requiring immediate correction. In cooperation with CDSS, MCDSES has voluntarily agreed to provide a correction plan within 30 days from the issuance of this report to correct the intake and screening process, and a timeline for completion. The plan should also evaluate and'incorporate the additional recommendations offered in this report. The CDSS will conduct an onsite review following voluntary implementation of the corrective action plan and issue a final report at that time. Page 12