Investigation Of The Death Of A Nicholaus Contreraz At Arizona Boys Ranch
And The Safety Of Children Remaining In That Placement
On March 4, 1998, the California Department of Social Services (CDSS) learned
of Nicholaus Contreraz's death at Arizona Boys Ranch (ABR). In response to this
information CDSS issued a letter to all County Welfare Directors, County Chief
Probation Officers, and Interstate Compact Coordinators suspending the use of
state and federal foster care funding for new placements at ABR pending CDSS
review.
A multidisciplinary team was assembled to (1) investigate the facts surrounding the
death of Nicholaus Contreraz, (2) examine the safety and protection of other
children at ABR, and (3) comment on procedures and policies related to protecting
children in out-of-state placements.
A nine-member investigative team was appointed that was composed of child
abuse and licensing investigators, a psychologist, an attorney, a foster care policy
analyst, and a representative from each of the following County Juvenile
Departments Los Angeles, San Bernardino, San Joaquin, and San Diego. They
spent 90 days completing a comprehensive investigation into the death of
Nicholaus and the safety and well-being of youth remaining in placement at the
facility. The investigation included interviews with California residents and past
residents of ABR, ABR staff and past staff, families of residents, and Arizona
government officials. Additionally, the investigative team reviewed Nicholaus'
medical records, autopsy report, and hundreds of documents related to issues
regarding ABR.
The findings, conclusions, and recommendations of the team were presented to an
oversight committee on June 22, 1998. The oversight committee concurred with
the recommendations of the team and forwarded them to the California State
Department of Social Services Director, Eloise Anderson, on June 26, 1998.
Nicholaus' death was caused by prolonged and serious medical neglect and
openly conducted abusive treatment. He suffered physical and psychological abuse
and his personal rights were continually violated. It is the finding of this report
that both the administration and staff knew or should have known about the abuse
and neglect which it failed to prevent or stop. The investigation also found
that the general philosophy of how youth are treated at ABR was not conducive to their safety and well-being and that ABR was not appropriately staffed to meet the various medical needs and psycho-sociological problems of their residents.
ABR has an extensive history of charges and a lack of follow-through in its corrective actions. Consequently, future placement consideration must be contingent on a plan of correction consistent with the majority recommendations. The plan must detail how changes will become a lasting part
of the policy and culture at ABR.
Additionally, this report recommends the State assess all current and future out-of-
state facilities serving California children to determine if the programs offer a safe
and healthy environment. The host states regulatory and enforcement programs
should be assessed to determine if they adequately protect the safety and interests of
children. There must also be a clear description of behaviors and needs that the
programs cannot accommodate.
The investigation into the death of Nicholaus Contreraz has resulted in a clear
picture of the operation of ABR. The findings, conclusions and recommendations
regarding this investigation offer a course of action to be taken by California with
regard to ABR placements. These findings also raise questions regarding all other
placements of California children in out-of-state facilities. No more is known
about other out-of-state facilities or their licensing programs than was known
about ABR and the State of Arizona at the beginning of this investigation.
Conclusions
Recommendations
For these reasons, this report recommends that the State (1) maintain the
moratorium against new placements at ABR, and (2) immediately remove the
California children who are currently residing at ABR