COUNTY OF LOS ANGELES

OFFICE OF CHILD PROTECTION
KENNETH HAHN HALL OF ADMINISTRATION
500 WEST TEMPLE STREET, ROOM 383
LOS ANGELES, CALIFORNIA 90012
(213) 893-2010

JUDGE MICHAEL NASH (RET.)

MEMBERS OF THE BOARD
HILDA L. SOLIS
MARK RIDLEY-THOMAS
SHEILA KUEHL
JANICE HAHN
KATHYRN BARGER

EXECUTIVE DIRECTOR

August 30, 2019
To:

Supervisor Janice Hahn, Chair
Supervisor Hilda L. Solis
Supervisor Mark Ridley-Thomas
Supervisor Sheila Kuehl
Supervisor Kathryn Barger

From:

Judge Michael Nash (Ret.)
Executive Director, Office of Child Protection

OFFICE OF CHILD PROTECTION (OCP) RESPONSE TO THE NOAH C. MOTION
On July 16, 2019, following the death of four-year-old Noah C., the Board of Supervisors directed County Counsel to oversee a review of the investigation into Noah C.’s
death by the Office of Child Protection (OCP) and report back on the following:
1. An assessment of the various interactions that any agencies may have had with
the family of Noah C., identifying any potential systemic issues or recommendations for modifying and/or strengthening services to optimally protect the health
and well-being of children
2. An update on the new pilot program in Palmdale and Lancaster that co-locates
social workers with law-enforcement agencies to increase cross-training and
coordination of joint responses and investigations of child-abuse reports
3. An update on the ongoing collaboration between law enforcement, the
Department of Children and Family Services (DCFS), and the District Attorney’s
Office, to enhance and improve the utility of the Electronic Suspected Child
Abuse Reporting System (eSCARS), with recommendations as appropriate
4. An update on the assessment of the existing use of the Medical Hubs Countywide, including efficacy of services and effective collaboration between and
among the departments of Health, Mental Health, Public Health, and Children
and Family Services to support the needs of children and families involved in
child protective services
5. In collaboration with DCFS, the Department of Health Services (DHS), and the
Department of Mental Health (DMH), an update on staffing and resources available in the Antelope Valley, understanding the unique nature of the region and
previous barriers experienced

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The Board further directed the Chief Executive Officer (CEO) to collaborate with DCFS
to identify positions that are experiencing recruitment and retention challenges in the
department’s Antelope Valley regional offices and provide recommendations to address
them, including financial incentives such as a pay differential and bonuses.
The Board further directed the OCP and DCFS to report back comprehensive data that
details the progress and improvements that have been made since the adoption of the
recommendations of the Blue Ribbon Commission on Child Protection (BRC), such as
proposed systemic and structural changes including, but not limited to, Medical Hubs;
impediments to the department’s progress, including workload ratios; the number of
fatalities that existed prior to the BRC versus now; and the overall efficacy of the OCP,
particularly towards prevention and including its accomplishments.
The Board further directed the CEO and the directors of DCFS, DHS, and DMH to
report back on the number of vacancies versus the total allocated positions, including
vacancies in the Antelope Valley.
In this report, the OCP will report on items 1 through 4 and on the comprehensive data
detailing the progress and improvements made since the adoption of the recommendations of the BRC. The other items requested by the Board will be reported on
separately by the CEO, DCFS, and other agencies.

1. History of Contacts and Systemic Issues Identified
The family of Noah C. consisted of mother Ursula, father José, and four children—Noah
and three siblings. Contact with DCFS fell into three different contexts. 1
▪ First, in August 2014, petitions for Noah and his older sibling were filed alleging
that Mother had physically abused her own infant sibling, resulting in a skull
fracture, and that Father was an abuser of marijuana. The petitions resulted in
the detention of Noah’s sibling and Noah, shortly after Noah’s birth.
▪ Second, petitions were filed in November 2016 alleging that Noah had been
diagnosed with “failure to thrive,” developmental delay, and congenital hypertonia, and that he was medically neglected by Mother and Father, who failed to
take the child to eight scheduled medical appointments. These petitions again
resulted in the detention of Noah and his sibling.
▪ Third, following the return home of Noah in November 2018, reports were made
to the DCFS Child Protection Hotline regarding Noah that contributed to the
issuance of a removal order on May 15, 2019, that was not executed.

1

When she was a child, the family of Mother was the subject of three DCFS referrals—one in 2001 and two in 2011.
The third referral resulted in a Voluntary Family Maintenance (VFM) case that closed as the family stabilized. When
Father was a child, his family was also the subject of three DCFS referrals, in 1999, 2001, and 2008. The 2008
referral was promoted to a VFM case that closed in 2009 as the family stabilized.

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2014 Petitions
After the filing of the petitions in August 2014, Noah and his older sibling were placed in
foster care and then with their maternal great-grandmother (MGGM).
On May 21, 2015, just prior to the adjudication hearing, the petitions were dismissed.
The allegations against Mother were dismissed after a forensic evaluation requested by
DCFS was received from Dr. Janet Arnold-Clark, M.D., Board Certified Child Abuse
Pediatrician from the LAC+USC Violence Intervention Program. DCFS requested the
dismissal after indicating that it did not have sufficient evidence to meet its burden of
proof, “as it is more likely than not that the mother did not cause the injuries.”
The allegations in the petitions against Father were dismissed because there was “no
evidence to suggest that the . . . father is an abuser of marijuana.”
Following the dismissal of the petitions, Noah and his sibling were returned to Mother
and Father.
2016 Petitions
After the filing of these petitions, both Noah and his older sibling were placed in foster
care. At the initial hearing on November 21, 2016, Noah’s sibling was released by the
court to Mother and Father over the objection of County Counsel.
On March 9, 2017, Mother and Father pled no contest to the petitions. The disposition
hearing was held on June 1, 2017. Family maintenance services were ordered for
Noah’s sibling, and family reunification services were ordered for Noah. On August 14,
2017, Noah was placed with his MGGM and maternal great-grandfather (MGGF).
At the Welfare and Institutions Code (WIC) section 366.21(e) judicial review hearing on
November 28, 2017, the court found by a preponderance of the evidence that the return
of Noah to his parents would create a substantial risk of detriment to the child, thereby
necessitating continued placement.
The court further found that the parents’ compliance with the case plan had been
substantial. Both had completed parenting programs and had provided proper care for
Noah’s sibling. Mother had not completed individual counseling, in part because she
had seen a counselor who was not a DCFS-approved licensed therapist. The court
liberalized visits for the parents with Noah after finding that previous visits had been
consistent and of high quality. The DCFS report on the November 28, 2017, hearing
indicated that both children were doing well. Overnight visits with Noah were set to
begin. The report noted that Mother and Father “have made tremendous progress” in
participating in and completing the court-ordered case plan. DCFS stated that the family
would be referred to family preservation services upon reunification with Noah. 2

2

There is no indication that this ever occurred after Noah was returned to his parents.

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The court continued reunification services and found a substantial probability that Noah
would be returned to his parents within 18 months of his removal. The case was continued for the next review pursuant to WIC section 366.21(f) on May 29, 2018. (At the
November 28, 2017, hearing, court jurisdiction was terminated over Noah’s sibling.)
At the May 29 hearing, Mother and Father contested the department’s recommendation
to continue family reunification services. The DCFS report noted that Mother and Father
were both compliant with their case plan and were taking good care of Noah’s siblings,
which included a new baby born on January 25, 2018. A return home for Noah was not
recommended because of the lack of consistency of overnight visits and difficulties in
transitioning Noah from the home of MGGM to parents when visits did occur. The
hearing was continued to August 27, 2018. The court also ordered Noah to be referred
for mental health services and for conjoint counseling with his parents.
As transition difficulties continued, the court ordered on July 11, 2018, a bonding study
to assess the bond between Noah and his parents and between Noah and the maternal
great-grandparents.
The August 27, 2018, hearing was continued until November 1, 2018. In the interim,
visits remained inconsistent and transition issues continued. Conjoint counseling did not
occur. A new continuing-services children’s social worker (CS-CSW) was assigned to
the case on September 7, 2018. The evaluation for the bonding study was completed
on September 21, 2018. The psychologist recommended that Noah be transitioned to
his parents with the assistance of Parent Child Interactive Therapy (PCIT).
On November 1, 2018, DCFS indicated its disagreement with the bonding study and
recommended that family reunification services be terminated and the case be set for a
permanency hearing pursuant to WIC section 366.26. At the November 1 hearing, the
court ordered Noah on an extended visit with his parents, over DCFS objections. The
hearing was continued to November 9.
On November 2, 2018, the CS-CSW visited Noah at the family home and he appeared
to be comfortable. Subsequent attempts to visit before the November 9 hearing were
unsuccessful.
On November 9, 2018, the court found that return to the parents would not create a
substantial risk of detriment to Noah. The suitable-placement order was terminated and
Noah was ordered to Home of Parents, over the objection of DCFS. The court further
ordered DCFS to make unannounced visits and to set up a visitation schedule for the
maternal great-grandparents, and for the parents and Noah to participate in PCIT. The
case was continued to May 9, 2019, for a judicial review pursuant to WIC section 364.
2019 Activities
Subsequent to the November 9, 2018, hearing, the CS-CSW had in-person visits with
Noah on November 16 and December 17 of 2018, and on January 24, January 25,
February 28, March 7, March 22, and April 17 of 2019. Noah was also seen by an

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emergency-response children’s social worker (ER-CSW) and Human Services Aide
(HSA) on May 20, 2019, and by the ER-CSW again on June 28, 2019. The CS-CSW
also made four unannounced visits, for three of which she could not see Noah and was
told via telephone by the parents they were not at home.
In her report to the court for the May 9, 2019, hearing, the CS-CSW reported, “During
this period of supervision, Noah appeared to be happy and bonded to his parents.”
During the period between November 9, 2018, and May 9, 2019, the parents did not
enroll in PCIT and Noah was not put in preschool. MGGM had only one visit, on March
23, 2019. Further, during this time period the family’s residence changed and the
parents did not appear to be forthcoming about their living situation, although none of
their apparent residences appeared unsafe.
On the February 28, 2019, visit, the CS-CSW described Noah as lethargic and advised
that his parents seek medical treatment. On March 7, 2019, Noah had a well-child exam
visit at Kaiser Permanente Panorama City. The assessment was, “Well child. Growth
and development within normal limits.” Noah was also diagnosed with an ear infection
and was prescribed medication.
On April 17, 2019, the Child Protection Hotline received an anonymous call indicating
that MGGM had seen Noah the previous week and he appeared thinner, with “frail hair,”
intimidated, and scared. The caller said that Noah frequented a maternal aunt’s home
and suffered from night terrors and had mentioned that his “butt hurt.” Further, the caller
said that the child had told the CS-CSW that Father hits him and curses at him. An “Info
to CSW” communication was generated and sent to the CS-CSW.
The CS-CSW went to see the child that day and he appeared scared that she was there
to remove him. He calmed down after she reassured him that she was not there to
remove him. The CS-CSW asked Mother to remove Noah’s shirt and she observed
cream on his back, which Mother said was for eczema. The CS-CSW noticed a bruise on
Noah’s back and a scab on his forearm. The CS-CSW took a picture of them. Mother said
that Noah had fallen from his brother’s bunk bed. In speaking to Noah, the CS-CSW
reported that he said he loved his mother and father. He also said there was nothing
wrong with his butt. He said Father does not call him bad names. He said that when he
does something wrong, he gets hit; when asked where, he said he doesn’t get hit. Noah
appeared happy and smiling during the interview. The CS-CSW felt he was coached.
The next day, the CS-CSW made a referral to the Child Protection Hotline and
emergency response. An ER-CSW was assigned the referral and later met with the
family. She observed the bruise on Noah’s back and arranged for a forensic exam at the
Olive View Medical Hub the next day. She spoke with Noah, who appeared happy. He
said he got the bruises when he fell off the bed. Noah denied any physical discipline,
sexual abuse, domestic violence, or fear of his parents.
A report of the April 19, 2019, forensic exam at Olive View indicated that Noah was very
happy and energetic and engaged with Mother. Other than the bruise on the back and

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elbow and scab on his elbow, the physical exam indicated that the rest of the body was
within normal limits. The report concluded, “It is plausible current markings/bruising
. . . can be attributed to the incident that was reported by both mother and child” (the fall
off the bed). No other physical findings were discovered during the examination.
On May 9, 2019, the ER-CSW consulted with the family’s prior CS-CSW (now an HSA),
who indicated that she had always had concerns for Noah, was opposed to his return
home, and felt that the parents are habitual liars who present well. She expressed concern for the bonding between Noah and parents and believed he was a targeted sibling.
On May 9, the ER-CSW also consulted with her supervising children’s social worker
(ER-SCSW). It was decided to close out the referral, given that the family was already
under court supervision. The allegations of physical abuse were found “inconclusive.”
There was no further discussion about the alleged night terrors or the complaint that
Noah’s butt hurt.
On May 13, the ER-SCSW consulted with the CS-SCSW and advised that the
allegations could not be verified. The CS-SCSW indicated that because of various case
concerns related to the parents not being compliant and truthful, the CS-CSW had
initiated a warrant request for removal (a DCFS procedure).
On May 15, a call to the Child Protection Hotline stated that the MGGM reported that
one of Noah’s maternal aunts had told her that Father beats Mother in front of the
children and sometimes throws them out into the street. Further, the MGGM said that
Noah spent the night at a maternal aunt’s home and woke up screaming in the middle of
the night. He also told the maternal uncle that his butt hurt, and the uncle told the aunt
that Noah was being sexually abused.
This Hotline referral was assigned to the same ER-CSW. On May 15, prior to any
investigation of the referral, the CS-CSW submitted the removal order to the court,
which signed the removal order the same day. There was disagreement among the
emergency-response and continuing-services staff about the filing of the removal order.
An attempt was made to withdraw it, but it had already been signed by the court.
On May 16 and May 20, 2019, the ER-CSW spoke with the maternal aunts and
maternal uncle referenced by the MGGM. All unequivocally indicated that the
allegations made to the Hotline were not true.
On May 20, the ER-CSW and the HSA saw the family at their new address in Palmdale.
Mother denied all of the latest allegations; she also denied being pregnant. Father, too,
denied the allegations. The workers also saw and spoke with Noah, who was alert and
in good spirits. Noah denied sleeping over at the maternal aunt’s house, denied that his
parents get in fights, and stated that he felt safe. He also pointed when asked to
indicate his private parts, denied sex abuse, and denied that his butt ever hurts.
At a case conference on May 22 attended by the ER-CSW, the CS-CSW, the HSA, the
ER-SCSW, and the Assistant Regional Administrator, it was agreed not to execute the

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removal order pending the referral. It was agreed that DCFS would facilitate a child and
family team (CFT) meeting with the family. Unsuccessful attempts were made through
July 5 to schedule a CFT.
On June 6, Mother—who had previously denied being pregnant—gave birth to a baby
boy. At the hospital, she initially denied that the baby was hers and claimed she was
inseminated as a surrogate, but did not know she was pregnant. She eventually told the
truth and said she was afraid of DCFS. Hospital personnel noted that Mother had had
no prenatal care and they were concerned with Mother’s mental health. The baby was
healthy and was discharged with his parents.
On June 13, the ER-CSW consulted with the ER-SCSW and it was decided to promote
Noah’s (now) three siblings to a case because of concerns for Mother’s mental health
and her inability to comply with court orders.
On June 19, the May 15 referral was closed. The allegation of general neglect by
Mother was substantiated. The allegations of abuse by Father were deemed
inconclusive.
On June 28, the ER-CSW visited the family home. All children were seen. Noah was
described as being in good spirits and reported that he was doing well.
On June 26, the court was informed that the April 18 referral was closed, but that a new
referral had been generated on May 15 alleging the sexual abuse of Noah and domestic
violence between the parents, and that the removal order granted on May 15 had not
been served. DCFS recommended a 30-day continuance to address the outcome of the
referral disposition for a possible new case filing as to Noah and his three siblings.
On July 5, Noah was hospitalized after parents said they found him in the apartment
complex’s pool. He passed away on July 6, 2019.
The death of Noah is under investigation by the Los Angeles Sheriff’s Department. No
further information is available at this time.
Conclusion
Given what is currently known, the primary issue in this case from a systemic perspective focuses on the removal order. There are three key questions. First, was it appropriate? Second, should it have been issued? Third, should the order have been executed
and Noah removed?
For clarification purposes, a “removal order” is not an order from the court directing the
department to remove a child from the home. It is an order authorizing a removal of a
child whom the department believes is at risk when there are not exigent circumstances
justifying a removal without a court order. If the removal order is not executed or served
within 10 days, the department must seek a new removal order if exigent circumstances

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do not exist. DCFS policy also mandates that the court that issued the removal order
must be notified if the child is not removed.
On the first question posed above, it is the opinion of this writer that the removal order
was not appropriate. While the affidavit was lengthy, the basis for removal was sketchy
for several reasons. The affidavit itself consisted of prolonged discussions of the
family’s background that included descriptions of the 2014 petition (which absolved
parents of responsibility and was dismissed), the 2016 petition that brought the family
before the court, and the sequence of events leading to Noah’s return to his parents in
November 2018.
By all accounts, Noah was doing well until around April 2019 and the CS-CSW was
considering recommending termination of the case at the next scheduled court hearing
in May, despite the fact that the parents had not complied with the court order to
participate in Parent Child Interactive Therapy, had not given the MGGM her regular
visits, and had not always kept DCFS informed of their address. Those factors in and of
themselves would not be sufficient for removal of the child, but could form a basis for
the court to maintain jurisdiction.
The affidavit further referenced the April referral that focused primarily on the back
bruise. However, following the forensic medical examination at the Olive View Medical
Hub, that allegation was deemed inconclusive as the injury seemed consistent with the
explanation given.
The affidavit also suggested that the parents were medically negligent because Noah
was not taken to a doctor when he appeared lethargic on February 28, and was not
taken to a doctor when he suffered the back bruise (the basis for the April referral).
Except for a minor ear infection diagnosed at Noah’s annual medical exam on March 7,
he was deemed normal both by the annual exam and by his Hub examination.
Finally, the affidavit discussed in detail the serious allegations that were the source of
the May referral. Those allegations, which included possible sexual abuse and domestic
violence, had not been investigated at the time that the removal order was sought.
These serious allegations could have been the sole basis for a removal order had they
been substantiated in any way—which they never were.
When all of the above is considered as a whole, there was not a sufficient basis to seek
a removal of Noah.
As to the second question, this writer believes that the court was correct in signing the
removal order because of the serious allegations regarding sexual abuse and domestic
violence. The court had no knowledge that those serious allegations had not been
investigated.
As to the third question, it is clear that the decision to not execute the removal order was
appropriate. Given the fact that the most serious allegations, stemming from the MGGM

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and the only reasonable basis for removal, had not been investigated, the removal of
Noah from his parents would have been a premature, if not inappropriate, action.
These conclusions are not meant in any way to denigrate the ability of social workers to
use their instincts based on their education, knowledge, and experience. However,
given that they have the significant authority to remove children from their homes, it
must be very clear that there exists a sufficient factual basis to exercise that authority.
Recommendations
A. Improve Warrant/Removal Order Process
The DCFS policy for obtaining warrants and/or removal orders is found in DCFS policy
0070-570.10. 3 It needs review and revision in a number of ways. First, the process for
obtaining a warrant or removal order needs to be clarified. It is not clear in existing
cases whether a court petition pursuant to WIC 342 or WIC 387 must be filed before or
after a removal order is obtained.
Once a warrant/removal order is obtained, the policy should be clear under what
circumstances it should not be executed, including what level of supervisory approval
and what specific documentation are necessary. A timeframe for notifying the juvenile
court that a removal order the court has previously approved is not being executed
should be included in the policy.
In addition, there should be ongoing training for those involved in the warrant process,
including DCFS and County Counsel personnel. In this case, a concern was expressed
as to whether or not a removal order should be sought. Additionally, a removal order was
filed despite the fact that it contained specific information that had not been investigated.
Perhaps more important, DCFS data show that in 2018, removal orders were sought for
8,952 children. For 687 children, those requests were denied. Seven removal orders
were not served. According to DCFS, departmental policy does not require staff to
report if warrants are not served. That policy needs to change.
Further, while the overall rate of denials is less than 10 percent, that still means that
removal orders were denied for hundreds of children. Therefore, it is recommended that
DCFS undertake a review of its process to understand why there are so many denials.
Is it a DCFS issue, a court issue, or both? Is DCFS seeking too many removals, or is
the documentation for its requests insufficient? It is important to know the answers to
these questions—ultimately, children’s lives can be at stake.

3

The 2014 version of this policy was revised on July 21, 2019, to require DCFS Director approval to not execute a
removal order issued by the court. The policy is currently under further review.

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B. Necessity for Seeking Review of Court Orders
In Noah’s case, the court issued important rulings over the objections of DCFS. The
most significant to these occurred in November 2018, when the court terminated the
suitable-placement order of Noah and returned him to his parents.
The hearing on November 9, 2018, was a status-review hearing pursuant to WIC
366.21(f). At that hearing, the court is required to return the child to the parents “unless
the court finds, by a preponderance of the evidence, that the return of the child . . .
would create a substantial risk to the safety, protection, or physical or emotional wellbeing of the child.”
In this case, DCFS (through its attorney, County Counsel) argued that the evidence
showed such a risk existed. The court disagreed and returned Noah to his parents. No
further review of the court’s ruling was sought by DCFS or County Counsel, despite
their contention that the child was at risk and despite the fact that potential legal
avenues are available to seek review of a court order. It should be clear that whenever
the court issues an order that DCFS and County Counsel believe is contrary to the
evidence and that places a child at risk, there is a legal and moral obligation to seek
review of that order.
C. Adherence to Statutory Timelines for Dependency Court Cases
WIC 352(b) provides that “ . . . if a minor has been removed from the parents’ . . .
custody, no continuance shall be granted that would result in the dispositional
hearing . . . being completed longer than 60 days after the hearing at which the minor
was ordered removed or detained, unless the court finds that there are exceptional
circumstances requiring such a continuance. . . . In no event shall the court grant
continuances that would cause the hearing . . . to be completed more than six months
after the hearing pursuant to Section 319.”
Noah and his sibling were the subjects of two petitions filed in the Dependency Court.
The first case was filed in August 2014 and was dismissed prior to its adjudication
hearing on May 21, 2015, a period of time just short of nine months. The recent case
was filed and heard at initial hearing on November 21, 2016, and did not reach a
disposition hearing until June 21, 2017, a period of time longer than five months.
Dependency matters—particularly those in which children have been detained from their
parents—need to be adjudicated as quickly as possible. While it is ultimately the responsibility of the court to control proceedings, DCFS and County Counsel, as well as other
parties, need to be watchful for delays in proceedings and should strongly advocate for
closer adherence to the statutory timelines established for these proceedings.