Excerpts of a report by the California Department of Social Service regarding the death of Nicholaus Contreraz at the Arizona Boys Ranch and the oversight role of the Ranch by the Arizona Department of Economic Security.

VI. ARIZONA DEPARTMENT OF ECONOMIC SECURITY

On April 7-9, 1998, and May 1, 1998, Team members interviewed staff from the Arizona DES Licensing Unit and Child Protective Services (CPS) Unit. Documents reviewed included the Licensing Unit's 1995-1998 file on CPS investigative material on California children at ABR. The CPS internal policy and implementation guides, Arizona statutes relating to CPS, and mandated child abuse reporting laws were also reviewed (Appendix 5.)

A. Comparison of California and Arizona Licensing Regulations

The following compares the applicable regulations in Arizona and California related to care facilities for children. This comparison is limited to regulations that address issues identified by the team. In Arizona, the licensed facility is referred to as an agency.

Findings

Arizona Regulations do not require unannounced facility visits.

  • Under California statute, the licensing agency has the authority to make an unannounced site visit at any time. By practice, announced visits are rare.
  • Under Arizona regulations, facility inspections may be announced or unannounced. By practice, visits are often announced. Annual renewal site inspections are announced.
  • In California, annual site visits are always unannounced

    Arizona regulations do not require a corrective action plan for each licensing violation.

  • When a violation is found, Arizona regulations permit the licensing agency to require the licensee to submit a corrective action plan.
  • California regulations require the licensing agency to issue a citation for serious violations, and the licensee is required to develop a plan of correction.

    Arizona regulations do not specify plan of correction deadlines.

  • Arizona regulations do not specify timeframes for the licensing agency to determine that a plan is required, and when it is to be submitted and implemented.
  • California regulations require an immediate citation and immediate development of a plan of correction by the licensee.
  • California regulations require that most plans of correction must be completed within 30 days.

    Arizona regulations do not require follow-up site visits to determine compliance with corrective action plans.

  • In Arizona, the licensing agency is permitted, but not required to monitor the licensee's compliance with the corrective action plan.
  • In Arizona, the licensing agency is permitted, but not required to make site visits to determine the agency's progress.
  • In California, timely completion of every plan of correction is verified either by the submission of convincing evidence by the licensee or an unannounced site visit.

    Arizona does not have the authority to assess a financial penalty for failure to correct a violation.

  • Arizona has no provision for the assessment of financial penalties for failure to correct an identified violation.
  • California has the explicit authority to assess a substantial financial penalty for each identified violation uncorrected by the plan of correction due date.

    Arizona regulations do not require site visits to investigate complaints.

  • California regulations require that a complaint investigation is initiated within ten days, and the investigation must include an unannounced facility visit.
  • Arizona regulations do not specify when a complaint investigation must be initiated, and they permit but do not require an announced or unannounced site visit.

    In Arizona a person convicted of child abuse or neglect who seeks employment in or a license for a child care facility is not identified.

  • California requires a criminal record background check for every person with child care responsibilities. For those in California less than two years, an FBI record check is also required. In addition, for every person with child care responsibilities, a check of the Child Abuse Central Index maintained by the California Department of Justice must also be conducted. People with significant criminal records or determined to have committed child abuse or neglect may be excluded from child care facilities.
  • Arizona requires a criminal record background check, but does not access FBI files or the Arizona Child Protective Services Central Registry.

    Arizona requires higher levels of education and experience for direct care employees.

  • Arizona regulations require either a high school diploma and one year of experience working with children or one year of college education in child welfare or human services.
  • California regulations require the attainment of 18 years of age and either on- the-job training or related experience in six general areas of resident care.

    Arizona regulations do not specify site administrator qualifications.

  • Arizona regulations require a supervisor for each facility, but no qualifications are specified.
  • California regulations require that the administrator of a large facility have a master's degree or bachelor's degree and/or extensive pertinent experience.

    California regulations do not specify direct care staff supervisor qualifications.

  • In Arizona, any person who supervises direct care staff must have extensive and pertinent experience and education.
  • Other than the regulations pertinent to site administrators, California regulations do not address supervisor qualifications.

    Regulations and laws in both states require that child care staff report suspected child abuse or neglect.

  • By California law and Arizona law and regulations, child care employees are mandated reporters of child abuse or neglect. Although the procedures vary, both states require child care employees to report suspected abuse directly to a child protective services or law enforcement agency.

    Regulations in both states require that facilities adopt and adhere to child admission criteria.

  • Arizona regulations require that child admission criteria is submitted and restrict the conditions in which a child not meeting those criteria may be admitted.
  • California regulations also require that admission criteria is submitted but prohibits the acceptance or retention of children whose needs cannot be fully met in the facility.

    Both states require physical examinations prior to or soon after admission.

  • Both Arizona and California regulations require a physical examination prior to admission or within specified timeframes following admission.
  • Arizona regulations require an annual medical examination after admission.
  • California regulations do not require annual medical examinations.

    Both states specify similar resident rights.

  • Both states prohibit child abuse, neglect, corporal punishment, and cruel or unusual punishment; additional details are provided in both states' regulations.
  • California and Arizona regulations restrict, but do not prohibit denial of communication as a disciplinary measure.
  • California prohibits the use of mechanical restrains other than postural supports and any discipline which violates a resident's personal rights.
  • Arizona permits mechanical restraints under specified circumstances and Arizona regulations are silent on discipline which violates a personal right.

    Both states prohibit interference with toileting.

  • Both states personal rights regulations prohibit interference with toileting.

    Both states prohibit verbal abuse, ridicule and humiliation.

  • Although California regulations are more detailed, both states prohibit these practices.

    Both states prohibit all forms of physical violence.

  • Arizona regulations prohibit maltreatment, abuse, cruel, unusual or corporal punishment, spanking, paddling, and all forms of physical violence inflicted in any manner.
  • California regulations prohibit corporal or unusual punishment, infliction of pain, and actions of a punitive nature.

    California and Arizona regulations differ on the screening of resident's mail.

  • In Arizona, staff may inspect mail for contraband; a term that is undefined in that state's licensing regulations.

  • In California, every child is guaranteed the right to send and receive unopened mail, unless expressly prohibited by court order or by the child's legally authorized representative.
  • In both states, telephone communications between residents and others must in most cases be confidential.

    B. Background

    Prior to mid-1996 the Licensing Unit and the CPS function of investigating allegations of abuse at Child Welfare Agencies (agencies) were under the control of the same program manager This manager was directly responsible for the oversight of the abuse investigations conducted on agencies whose licensing was also under the same manager's review and responsibility.

    In July 1995, ABR filed a civil complaint against the Arizona DES; ABR Operations. Inc. v. State of Arizona. (Appendix 6a) This action resulted from thirteen substantiated abuse and neglect findings against ABR by the Arizona DES in 1994. The substantiated findings included serious physical abuse, potential for abuse and neglect, moderate physical abuse, medical neglect, minor abuse or neglect, and failure to notify DES.

    The complaint alleged that the substantiated findings were "contrary to law and invalid" and that no substantial evidence was presented to support the findings. They further contend that DES' decisions were "arbitrary, irrational, and capricious." In support of this contention, ABR cited that DES failed to accurately report taped interviews and consider the background of the complaining witnesses and former staff. In addition, the complaint alleged that DES failed to remain neutral and unbiased, erroneously applied licensing standards and failed to consider exculpatory evidence.

    ABR further stated that as a result of the substantiated findings, they have been labeled "child abusers" and their Fourteenth Amendment due process rights were violated. The lawsuit seeks to enjoin DES from "further enforcement of their investigatory regulations and procedures" concerning child abuse allegations. They also sought a stay to prohibit DES from disseminating information to outside agencies until the final disposition of the action.

    This action has been continued numerous times. However, oral argument is set for June 18, 1998 on the issue of damages. No date has been set to hear the equitable issues. Hence, the lawsuit is still pending.

    According to DES staff the lawsuit was a "catharsis" for change in that it had long been an issue for one manager to oversee both the licensing and investigative functions. In mid-1996 DES separated the investigative function from the Licensing Unit and made it a part of the overall CPS unit.

    C. Child Protective Services

    In Arizona the responsibility for overseeing the welfare of children rests with the Department of Economic Security, Division of Children' Youth and Family. The CPS Unit is also under this division.

    By state statute the child protective services worker shall: ". . .receive reports. . .of abuse. . . notify the municipal or county law enforcement agency . . . make a prompt and thorough investigation . . . render a written report . . ."

    ln Arizona, CPS remains a state function and is not contracted to counties as it is in California. Arizona CPS has district offices throughout the state to handle the majority of abuse allegations, those that involve children not in placement in state licensed agencies. District office staff are known as CPS specialists. The CPS staff whose primary function is to investigate allegations of abuse occurring in licensed agencies are known as CPS program specialists.

    The CPS also maintains the state's Child Abuse Central Registry where people whose actions were investigated and found to be substantiated for committing child abuse are listed. The burden of proof for substantiation of abuse is "probable cause."

    D. The Relationship Between CPS, Licensing and ABR

    Findings

    CPS is not required to inform an alleged victim's probation officer of the allegation or the outcome of the investigation.

    Suspects may continue to provide direct child care during an investigation. The agency has the ability to dispute the substantiated abuse findings.

    Once a referral or complaint is made to CPS, a cross report is made to the local law enforcement agency. Normally, the reports are mailed or faxed. Depending on the seriousness of the complaint, a report may be made by telephone. There are no internal CPS policies addressing how a report to law enforcement is documented in the investigative file.

    If the referral or complaint involves a licensed agency, a copy of the referral is sent to the Licensing Unit. The Licensing Unit reviews the referral and handles the portion of the referral that falls under their Jurisdiction (i.e., if the referral alleges abuse and lack of food for example, the Licensing Unit would investigate the lack of food only. The only time the Licensing Unit will conduct the abuse allegation investigation is if, at the time of the referral, the victim is over the age of 18 and resided in a licensed agency when the alleged abuse occurred.

    According to CPS staff, there is no mandate or policy which dictates that the alleged victim's case manager or probation officer is informed of the abuse allegation. However, the agency is notified within two hours of receipt of a child abuse referral. Additionally there is no mandate that the case manager or probation officer be notified of the outcome of the CPS investigation.

    During the course of the investigation, CPS can request an agency reassign an alleged suspect from direct child care responsibilities. If the agency disagrees with this request, CPS has no recourse but to remove children from placement. At any time, CPS can share licensing concerns with the Licensing Unit. The Licensing Unit evaluates the information and requests corrective action from the agency if required.

    Prior to January 1, 1998, a completed CPS investigation report was sent to the Licensing unit for review. The Licensing Unit would determine if any licensing regulations had been violated and take appropriate action (i.e., request a Corrective Action Plan). CPS would also inform the agency of its findings.

    A licensed agency can request a "staffing" if they disagree with the CPS findings. The "staffings" are held with CPS and Licensing management and allow the agency to bring in information they feel will have an impact on the findings. Management can, if necessary, change the findings. According to the Licensing Unit manager, no CPS findings involving ABR have ever been changed after a "staffing." It should be noted that ABR requests "staffings" more than any other agency licensed by the state. ABR contends that no licensing violation decisions should be made prior to a "staffing" and a final decision by CPS.

    On January 1, 1998, a new law became effective which changed how CPS deals with allegations of abuse at licensed agencies. The law provides the suspect of abuse the right to appeal the CPS findings before they were sent to the Central Registry. The new law also requires DES/CPS to notify the suspect of the intent to substantiate the allegation made against them within 14 days after the completion of the investigation. Statute does not define when an investigation is complete.

    The suspect has 14 days to request a hearing to appeal the findings. Once the request is made, the suspect is given the opportunity to provide supportive information that the finding should be changed. If DES/CPS agrees the finding is changed and no hearing occurs. If DES/CPS disagrees, a hearing is held before an Administrative Law Judge within 60 days.

    The CPS staff stated that the new appeal process does not prohibit them from requesting that a suspect be re-assigned from working with children. Licensing Unit staff stated that they are unable to take any action against a suspect until the suspect's appeal rights have been exhausted. There remains some confusion on this issue. Contributing to this issue is the length of time it takes for a CPS investigation to be completed. The CPS investigations routinely take many months. A recent ABR investigation, based on a October 31, 1997 referral, was not completed until February 5, 1998. This case was substantiated; however, DES did not request that the suspect who had direct child care responsibilities be reassigned. The suspects have requested an appeal of the findings and presumably are still employed at ABR. Licensing staff was unaware of the findings of this case until a Team member brought it to their attention.

    E. Licensing History at ABR

    Findings

    ABR has a history of numerous licensing violations.

    On several occasions, ABR has been issued a provisional license.

    DES has repeatedly failed to inform ABR of licensing violations in a timely manner.

    DES has failed to request CAPs from ABR when they have determined licensing violations exist.

    DES agreed to a procedure that conflicted with child abuse reporting requirements.

    DES agreed to a procedure that prevented them from conducting unannounced visits.

    DES agreed to a procedure that prevented them from obtaining documents that were necessary for effective monitoring.

    DES allows ABR to operate in a manner that prohibits DES from ensuring the safety of children in the care of ABR.

    The Licensing Unit maintains the responsibility for licensing, inspecting and monitoring approximately 90 Child Welfare Agencies for compliance with Arizona's licensing rules and regulations (Article 74 - Licensing Process and Licensing Requirements for Child Welfare Agencies.)

    The Licensing Unit typically makes yearly relicensing visits (Appendix 6b) and responds to complaints made against the licensed agency in regards to violations of the licensing regulations (i.e., issues regarding health and safety of residents). Licensing inspections and complaint visits can be announced or unannounced.

    If licensing determines that a regulation has been violated, it notifies the agency of that finding and requests that the agency develop a Corrective Action Plan (CAP). If licensing feels a CAP is required, and the agency fails to comply with this request, licensing's only course of action is to issue a provisional license, deny the renewal of a license or revoke a license.

    Arizona Boys Ranch has a history of numerous licensing violations documented by DES which, in the past, has either resulted in the issuance of a provisional license or the voluntary relinquishment of their license. (Appendix 6c) In 1987, with many of the current administrative and management staff in place, ABR "voluntarily" relinquished their then-existing license. This relinquishment coupled with an agreement to implement a corrective action plan resulted in the issuance of a provisional license effective October 16, 1987. The DES issued the provisional license in spite of what they termed "the seriousness of these violations." (Appendix 6d)

    In addition, the "corrective action plan" allowed for the transfer of involved staff "to a position without direct contact with, nor responsibility for, the ABR residents." Some of those staff are currently in management positions at ABR.

    The numerous substantiated findings which led to the 1987 action resemble many of the practices and procedures disclosed during the current investigation. They included the following:

    Corporal or other cruel punishment

  • residents were slapped in the face
  • residents were punched in the body
  • residents were grabbed and picked up by their throats
  • residents were slammed into the wall
  • residents were kicked in the rear
  • residents had their faces pushed into the ground
  • residents had their neck and chest stepped on

    Physical restraints were used for punitive purposes

    Health standard violations

  • residents were permitted only five minutes to eat meals
  • residents were permitted two minutes to shave
  • residents were permitted one minute to shower
  • some residents were required to go to bed one-half hour later and arise one-half hour earlier than other residents as a form of discipline

    Meals

  • residents were permitted only five minutes to eat meals

    Staff Conduct, Personal Attitudes and Standards

  • Staff conduct and attitudes did not represent those qualities and values which children need to respect and emulate

    In-Service Training

  • staff did not have proper training or chose to ignore it

    Reports

  • staff failed to report unusual incidents to DES and the placing agencies

    Disciplinc and Control

  • same findings for corporal punishment, restraint, health and meals

    In 1994, numerous allegations of abuse were reported to CPS/Licensing, investigated ant substantiated. The majority of the abuse occurred during "addressings" or "restraints."

    In June 1994, due to the substantiated findings and resulting licensing violations, ABR was issued a provisional license for non-compliance in the areas of corporal punishment, restraints used for punitive purposes, failing to report unusual incidents and failing to maintain accurate statistics on children in care. ABR was required to report to the CPS/Licensing Unit, all incidents related to suspected child abuse, all incidents in which a resident was injured during a restraint or disciplinary action, and all incidents where a resident required medical attention. In addition, all unusual incidents were to be reported to Licensing.

    Between June - December 1994, ABR requested a hearing regarding the provisional license. This request was denied. ABR hired a private investigative team to conduct an investigation of the substantiated findings. They requested "staffings" which were delayed until ABR's team completed their investigation.

    On December 30, 1994, ABR's provisional license was restored to a regular license due to ABR's "resolution" of previous licensing concerns. No documents were found in the licensing file to reflect the terms and conditions of that "resolution."

    Despite documented concerns by DES staff, on June 30, 1995, ABR was issued regular licenses effective June 30, 1995 until June 30, l996. (Appendix 6e) They were asked to provide a CAP for reporting incidents when residents were injured and for maintaining and making available records to licensing in a timely manner. This CAP resulted from a resident's statement that he had been choked and scratched by staff. This incident was substantiated in August 1995. These requests were similar in nature to those which resulted in the June 1994 provisional license.

    On July 14, 1995, ABR refused to provide the CAP and claimed the request to report an injury was based merely on an allegation before it had been investigated and substantiated. (Appendix 6f)

    The ABR also stated its reports were "internal memoranda" used for communicating among staff, and that the information from them was entered into the resident's progress reports. They further claimed restraint reports were forwarded to the placement agencies and were not kept in the residents' files They stated those reports were available upon specific request and that in general they did not fall under the definition of "unusual incidents."

    The DES continued to request that a CAP be submitted ant claimed that licensing staff had been denied the ability to review records. ABR states there was no denial, and that they had no records for licensing to review. Also at this time (August 1995), ABR's Investigative Team completed their report and requested that DES review it. DES reviewed the report and made no changes to the original CPS findings.

    On September 27, 1995, ABR filed a lawsuit against DES/CPS staff (See Background).

    On November 6 and 7, 1995, during a licensing visit at ABR, licensing staff were not allowed to talk with staff or residents or to review reports. (Appendix 6g)

    On November 22, 1995, an agreement was made between the Attorney General's Office, DES and ABR (Appendix 6h) The agreement included the following:
    1) DES would notify ABR 48 hours prior to a visit.
    2) ABR would give DES requested records upon 24 hours notice.
    3) All interviews conducted by DES of ABR residents would be tape-recorded and ABR would get a copy (this was ultimately changed to redacted transcripts.)

    On March 12, 1996, during a licensing visit, requested records were again denied to the licensing worker. The worker was only allowed to look at redacted records. (Appendix 6i)

    On May 30, 1996, during a licensing visit, licensing staff saw reports that revealed one resident had body lice and one had been seen at the hospital for an infection of his cheek. Licensing staff felt these incidents needed to be reported to DES as unusual incidents. ABR contended these were "medical conditions," not injuries or illnesses which were reportable. (Appendix 6i)

    Despite significant internal dissent, on June 28, 1996, DES issued licenses to ABR effective until June 29, 1997. (Appendix 6k) Between June 30, 1995 and July 1996, numerous CPS investigations were conducted and substantiated. Some of these investigations were "staffed," however, no changes to the findings were made. During this one-year period at least six draft letters requesting CAPs were written, but were never sent to ABR. (Appendix 61) On June 10, 1996, the Licensing Unit asked management to notify ABR of violations discovered during this time period. No response was found as to why there was a delay.

    On July 24, 1996, DES informed ABR of their "expectations" to maintain compliance with licensing rules and regulations. (Appendix 6m) This request did not contain language that would have made it a request for a CAP. The "expectations" included

    Reports - All unusual incidents and restraint/control reports to go to DES and the placement agency within certain time frames.

    Discipline and Controls. Corporal Punishment. Operations Manual - ABR is expected to define in writing and incorporate into its operations manual the policy and procedures relative to "escalation," "hands-on treatment," "addressings," etc. Policy should include consequences for staff who fail to follow the policy and documentation of staff training on these policies

    Physical Restraints - must be documented and maintained in the child's file.

    On August 5, 1996 ABR responded to these "expectations" claiming they were not justified by the rules and regulations. ABR claimed, that the definitions of "escalation" and "addressing," would be "either impossible or worthless." (Appendix 6n)

    With some internal dissent, on April 1, 1997, ABR and DES entered into a "Memorandum of Understanding" (MOU) which outlined procedures relating to the reporting of unusual incidents. (Appendix 60) In summary, those procedures stated;

  • The ABR staff attorney will determine which incidents are to be included on a reporting chart. The Licensing Specialist will review the chart three times during a 90-day period (starting April 1, 1997.) The Licensing Specialist can request and ABR will provide incident reports related to the incidents on the reporting chart. The Licensing Specialist can only ask for 10 percent or three reports, whichever is greater. ABR is allowed to provide redacted copies of the reports requested by the Licensing Specialist.

  • If during this review and during any monitoring of ABR, the Licensing Specialist discovers a licensing violation (actual or potential), that staff will meet with ABR to discuss the issue and/or obtain more information in order to resolve the matter.

  • The Licensing Specialist, upon learning of an allegation of abuse or neglect, will meet with the ABR attorney to discuss the allegation. If the ABR attorney agrees this allegation needs to be reported to CPS then ABR will do so. If no agreement is made, then the Licensing Specialist will tell ABR that they will make the report to CPS and will do so. If the ABR attorney and the Licensing Specialist both agree that no report is required, then no report will be made.

  • ABR agreed in the MOU to report incidents resulting in resident injuries (except for sports-related injuries) to DES. Those injuries would require follow-up with medical professionals other than ABR medical staff in order to qualify for this reporting agreement.

  • ABR agreed to prepare a summary chart regarding physical restraints and control position incidents in which a resident is injured, but is only seen by ABR medical staff.

    The MOU allowed ABR to be selective in what it reported to DES, as DES had no mechanism in place to determine if all the incidents were in fact entered into the chart. ABR has for years claimed that they send all restraint incident reports to the placement agencies. DES does not contact placement agencies to see what incident reports they have received.

    This MOU remained in effect until July 1, 1997, when licensing rules and regulations changed, requiring that all unusual incidents be reported to both DES and the placement agency. Prior to July 1, 1997, the rules did not require that reports be sent to DES. Agencies had the option of sending them to DES or the placement agency.

    On July l0, 1997, an annual relicensing study report revealed several licensing violations including failing to have the proper proof of education in personnel files, physical plant and medication issues. ABR was issued a license effective July 1, 1997, through July 2, 1998. (Appendix 6p)

    VII. Closing

    Conclusions

    The investigative team reached consensus on the following conclusions

  • About Nicholaus:

  • The combination of medical neglect and abusive treatment caused Nicholaus's death.
  • Nicholaus showed obvious signs of illness that went untreated over a long period of time.
  • The abusive treatment of Nicholaus was openly conducted and permitted.
  • Recognition of Nicholaus's illness was not a challenging task.
  • The condition could have been successfully treated if recognized early
  • Nicholaus's medical needs were severely neglected.

  • About ABR:

  • Physical abuse, psychological abuse and personal rights violations were endemic at Oracle.
  • The abuse compromised the safety and well being of children and caused some of them to live in fear.
  • Staff at Oracle were not adequately trained or supervised.
  • Staff at Oracle were encouraged by their peers and supervisors to be physically aggressive with children.
  • The environments at Oracle and Main Ranch were very different.
  • Staff at Oracle and Main Ranch did not know the mandated child abuse reporting law.
  • The environment at ABR discourages reporting of child abuse.
  • ABR's discipline, personal rights, and physical control practices are ill-defined and contribute to abusive staff behavior.
  • ABR's administration knew or should have known about the abuse and neglect and failed to prevent or stop it.
  • ABR's medical staff failed to maintain professional objectivity.
  • ABR is inadequately prepared to recognize and respond to mental health issues.
  • Current findings are consistent with findings from previous investigations.
  • The vast majority of problems occurred due the orientation phase at Oracle.

  • About Arizona DES/CPS:

  • There is no system at DES/CPS to inform placement agencies of abuse at ABR.
  • DES does not effectively enforce licensing regulations at ABR.
  • The Arizona DES provides inadequate oversight to allow for the safety of children at ABR.

    Recommendations regarding ABR

    Based on the findings and conclusions, a majority of the Team members formulated the following recommendations regarding ABR:

  • Majority Recommendation - Maintain the moratorium against new placements at ABR, immediately remove the California children who are currently residing there and only consider new placements at ABR after the following conditions are met:

  • Prior to placement at ABR, the placement agency must ensure that each child receives an assessment which specifically addresses the medical end mental health risks of placement in the program ABR provides.
  • The placement agency and ABR must develop a screening process that carefully matches a child's treatment needs with the program ABR offers.
  • The placement agency and ABR must develop a system to identify and remove residents who are inappropriate for the ABR program.
  • ABR must maintain the current positive changes and initiatives that have been announced to juvenile court judges, placing agencies and probation officers.
  • ABR must change its current leadership.
  • ABR must provide an independent Ombudsman, who must be administratively separate from ABR staff, to provide unrestricted liaison services between the residents and the placement agency.
  • ABR must administratively separate its health care providers from other staff so that the provision of health care does not become a part of the disciplinary process.
  • ABR must cease to use violence and intimidation as a means of discipline, incorporate positive alternatives and promote the use of these alternatives through policy, procedures, and training.
  • ABR must provide residents with academic instruction during every phase of the program.
  • ABR must ensure residents have unrestricted and unlimited communication with their probation officers.
  • ABR must ensure residents are allowed uncensored mail and unmonitored telephone calls with family.
  • ABR must provide continuous staff training to include the following areas: child abuse issues and reporting laws, child development, health and mental health issues.
  • ABR must restructure its orientation program to conform to California's licensing standards.
  • ABR must revise its policy and procedure manuals to specify guidelines which delineate permissible and non-permissible disciplinary-procedures.
  • ABR must send all incident reports, including restraint reports to DES and the appropriate placement agency.
  • ABR must allow DES complete access to all records related to the care and supervision of residents.
  • DES must check the child abuse index to ensure that ABR staff are not listed on the child abuse registry.
  • ABR must implement a criminal record clearance process for staff which includes subsequent arrests or convictions.
  • Residents who resided at Oracle at the time of Nicholaus' death should receive mental health assessments for post traumatic effects.
  • Refer this report to the U.S Attorney's Office for review of civi1 rights violations.
  • Refer this report to the U. S. Department of Health and Human Services for review.
  • Refer this report to the Arizona Attorney General�s Office for review.

  • Minority Recommendation - While concurring with most of the findings and recommendations of the committee, three members differed in their recommendations regarding children currently placed at ABR.




    California investigation excerpts

    DES interoffice memo
    It's not my faultInterview with nurse Linda Babb
    Members of Congress ask GAO to investigate
    Justice Department and FBI open investigations
    California cuts funding to Arizona Boys Ranch
    California investigation rips Arizona child protection agency
    Report excerptsCalifornia blasts Arizona agency
    California report summary
    California Department of Social Services news release July 7, 1998
    Directive to all California county probation officers and social service departmentsJuly 7, 1998
    Letter to Arizona regulatorsJune 19, 1998
    Who's guarding the kids from the guards?
    One hundred twenty days
    Arizona Boys Ranch Operating Permit extended
    Sheriff's initial incident report
    Prosecutor's reviewing evidence
    Case may be too big for Pinal County prosecutors
    History of abuse known by state
    Time to keep the kids in California
    Nurse wants her name cleared in death of NicholausOne dead kid isn't enough???
    Justice for Nicholaus

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