Report 2011-101.1 Recommendation 9 Responses

Report 2011-101.1: Child Welfare Services: California Can and Must Provide Better Protection and Support for Abused and Neglected Children (Release Date: October 2011)

Recommendation #9 To: Social Services, Department of

To encourage county CWS agencies to conduct formal internal death reviews, Social Services should revise its annual report on child deaths resulting from abuse or neglect to provide information on whether county CWS agencies conducted such a review of child deaths with prior CWS history. To obtain this information, Social Services should revise its regulations to require all county CWS agencies to not only report child deaths resulting from abuse or neglect but to also require a subsequent report indicating whether an internal child death review was completed.

Agency Response*

CDSS continues to disagree with this recommendation and will not implement, for the reasons stated in the Department's prior response.

  • Response Type†: Annual Follow Up
  • Response Date: November 2016

California State Auditor's Assessment of Status: Will Not Implement


Agency Response*

CDSS continues to disagree with this recommendation. Reasons for disagreement along with actions taken in response to the recommendations are described below. CDSS agrees that there is great value in counties conducting child death reviews, but continues to disagree with the recommendation that the annual statewide child fatality report should be used to encourage or monitor such reviews. CDSS issued All County Information Notice I-45-12 on September 21, 2012 (attachment emailed) to encourage counties to 1) review cases of child deaths that are determined to be the result of abuse and/or neglect in which the child/family was known to and/or received services from the county CWS agency, or had prior CWS history; 2) annually reconcile the CWS agency's child death information with data from other entities that review child deaths, such as county child death review teams (CDRT); and 3) participate in meetings of local CDRTs when the opportunity is available. Whereas the annual statewide report is an appropriate vehicle for reporting statewide data and systemic issues, it is not an appropriate mechanism for reporting local, county-specific data and issues such as 1) compliance or consistency in the completion of local child death reviews or 2) local systemic issues requiring local change as identified as a result of such reviews. Rather, local systemic issues are best addressed through the County Self-Assessment (CSA) and System Improvement Plan (SIP) processes. Accordingly, CDSS incorporated, within updates to the manual for the CSA processes in the California Child and Family Services Review, instructions for a county to include systematic issues that arise from child death reviews and the process by which counties participate in local CDRT, if applicable, into a county's SIP. An update to the manual was released in All County Letter 13-93, issued on December 9, 2013 (attachment emailed).

  • Response Type†: Annual Follow Up
  • Response Date: October 2015

California State Auditor's Assessment of Status: Will Not Implement


Agency Response*

The CDSS continues to disagree with this recommendation for the reasons noted below.

CDSS agrees that there is great value in counties conducting child death reviews. Whereas the annual statewide report is an appropriate vehicle for reporting statewide data and systemic issues, it is not an appropriate mechanism for reporting local, county-specific data and issues such as 1) compliance or consistency in the completion of local child death reviews or 2) local systemic issues requiring local change as identified as a result of such reviews. Rather, local systemic issues are best addressed through the County Self Assessment (CSA) and System Improvement Plan (SIP) processes. Accordingly, CDSS has incorporated, within updates to the manual for the CSA processes in the California Child and Family Services Review, instructions for a county to include systematic issues that arise from child death reviews and the process by which counties participate in local child death review team, if applicable, into a county's SIP.

  • Response Type†: Annual Follow Up
  • Response Date: October 2014

California State Auditor's Assessment of Status: Will Not Implement


Agency Response*

Remains Not Implemented/Disagree with Recommendation. Though CDSS agrees that there is great value in counties conducting child death reviews, CDSS continues to disagree with the recommendation that the annual statewide child fatality report should be used to encourage or monitor such reviews. Whereas the annual statewide report is an appropriate vehicle for reporting statewide data and systemic issues, it is not an appropriate mechanism for reporting local, county-specific data and issues such as 1) compliance or consistency in the completion of local child death reviews or 2) local systemic issues requiring local change as identified as a result of such reviews. Rather, local systemic issues are best addressed through the County Self Assessment (CSA) and System Improvement Plan (SIP) processes. Accordingly, CDSS has incorporated, within updates to the manual for the CSA processes in the California Child and Family Services Review, instructions for a county to include systematic issues that arise from child death reviews and the process by which counties participate in local CDRT, if applicable, into a county's SIP. This manual update is planned for release in the Fall of 2013.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: Fall 2013
  • Response Date: October 2013

California State Auditor's Assessment of Status: Not Fully Implemented


Agency Response*

Social Services disagrees with this recommendation because it does not believe that its annual report on child deaths is an appropriate vehicle for encouraging counties to conduct formal death reviews. It also does not believe it has the statutory authority to require counties to conduct formal death reviews or report completion of these reviews to Social Services. Rather, Social Services points to the letter it released in September 2012 encouraging counties to conduct formal internal child death reviews. As we indicate on page 90 of the audit report, Social Services' plan for implementing this recommendation fails to create a mechanism to determine whether county CWS agencies are heeding its advice. If enacted, AB 1440 would have implemented our recommendation by requiring county CWS agencies to submit death reviews to Social Services and by requiring Social Services to include in its annual report information on whether county CWS agencies completed formal death reviews. AB 1440 was not enacted during the 201112 legislative session.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: Unknown
  • Response Date: November 2012

California State Auditor's Assessment of Status: Not Fully Implemented


All Recommendations in 2011-101.1

†Response Type refers to the interval in which the auditee is providing the State Auditor with their status in implementing recommendations made in an audit report. Auditees must submit a response regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year or subsequent to one year.

*Agency responses received after June 2013 are posted verbatim.


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