http://www.fresnobee.com/local/story/8486312p-9329387c.html
Savina's Story
A girl's death focuses attention on the Fresno County system charged
with protecting children in crisis.
By Jim Davis
The Fresno Bee
(Updated Sunday, April 25, 2004, 6:51 AM)
Savina Gonzales starved to death on a couch in her mother's home.
The 2 1/2-year-old girl lay wrapped in blankets with a bruised right
eye, a scar over her left rib cage and a cut lip. She weighed 13
pounds when her body was found April 28, 2003.
Nearly a year later, Savina's death is focusing attention on a Fresno
County child protection system that was charged with the girl's safety
for much of her brief life. The system, designed to protect the
county's defenseless and abused children, failed her.
"Basically, what the system does is take them out of a very
dysfunctional family and you put them in a very dysfunctional system,"
Fresno County Board of Supervisors Chairwoman Susan B. Anderson says.
Savina and two children in the county's child protection system died
within a month last year.
On April 21, 2003, 15-year-old Anthony Cortez was choked to death by
another youth in a group home in Stockton. On May 14, 4-month-old
Christopher Battie died of sudden infant death syndrome.
The reverberations from these deaths still are being felt.
A panel created by the county following Savina's death says the system
is so complicated that its employees too often get lost in details and
lose sight of their fundamental goal -- protecting the county's most
vulnerable children.
The panel found: Social workers who were undertrained and
inexperienced handling particularly difficult cases.
Supervisors relying solely on social workers rather than also speaking
with foster parents.
A system that fails to review what went wrong when a child dies under
its care.
Perhaps most frustrating to those familiar with foster care in Fresno
County is that the current concerns aren't new. Numerous reports
designed to improve the county's child protection system have been
written over the decades, all with no discernible effect.
Says Nancy Richardson, who helped write the most recent report: "About
every five years, a report is done and then usually the group ...
disbands. Then, a few years later, another incident causes people to
be concerned and a group forms and writes another report."
Fresno County officials say they are trying hard to improve the child
protection system.
They say they face a herculean task, trying to find safe havens for
more than 2,700 children whose parents are unable or unwilling to care
for them.
"These kids are not only the department's responsibility," Department
of Children and Family Services Director Gary Zomalt says. "The
department steps in after the family has failed and the community has
failed, and attempts to pick up the pieces and put them back
together."
Fresno County's policy is to do everything possible to reunite the
child and the biological family. The thinking is that it's best for
the child if the problems at home can be corrected and the family
preserved.
Savina was one of the county's "attempts to pick up the pieces." She
was taken from her biological mother at birth after mother and
daughter tested positive for drugs. Savina spent more than a year with
foster parents, then was returned to her biological mother.
As the anniversary of Savina's death approaches, surviving relatives
and former foster families wonder why the little girl was returned to
a woman who once told authorities she took drugs during pregnancies
because she was "stressed and experiencing morning sickness."
They also question why no one has been arrested in a case that the
Coroner's Office calls a homicide.
"It's like Savina's life and death didn't matter," says Annette
Whitley, Savina's foster mother for about 10 months.
Not true, says Department of Children and Family Services Assistant
Director Cathi Huerta: "Nothing shakes a department more to its very
soul than losing a child. You always question what you could have
done."
County officials say the justice system hasn't forgotten Savina.
Prosecutor Alvin M. Harrell III says the investigation continues.
Anderson says she has spoken with District Attorney Elizabeth Egan
about why the case has taken so long.
Many who knew and loved Savina are planning a private vigil this week
on the first anniversary of her death.
Says Savina's aunt, Korena Sanchez: "At the end of the day, it always
comes down to this -- how the hell did this happen?"
Savina looks happy in pictures from her short life. In one, she lies
against a teddy bear, her brown eyes beaming, her hand reaching out.
In another, she smiles from a stroller on an outing to Chaffee Zoo.
But her life took a tragic turn.
Savina's mother, Darlene Sanchez, 35, refused four requests for
interviews, including twice when approached at home. She says she is
protecting her other children.
The Bee pieced together details of Savina's life and death after
obtaining more than 500 pages from her foster file through a court
order and interviewing her foster families and other relatives.
Savina, the seventh of Sanchez's eight children, was born Sept. 5,
2000, at University Medical Center in Fresno. Tests revealed that
mother and daughter had cocaine in their systems.
Sanchez denied using drugs, telling social workers that her
brother-in-law might have spiked her soda. She later told a social
worker she snorted cocaine three days before giving birth, according
to the case file.
Social workers placed Savina and two siblings, Rebecca, then 2, and
Roy, then 1, in foster care. State law allows children to be taken
from their parents if they have been abused or neglected, including if
a newborn tests positive for drugs.
Sanchez's other children already had been taken away permanently. She
had been involved with the child protection system since 1990. Her
criminal record includes being charged with suspicion of willful
cruelty to a child; it was dismissed after she completed a parenting
class.
While Rebecca and Roy were placed in one foster home, Savina was
placed in the home of Nancy Glazebrook of Fresno, who specializes in
caring for medically fragile infants. After about two weeks, she was
moved into Annette Whitley's Coalinga home.
Foster care is designed to make such arrangements temporary. State law
requires children under the age of 3 to be in foster care for no
longer than a year before a decision is made on adoption or
reunification.
Soon after Savina's birth, Sanchez began efforts to get her three
children back. A family reunification panel, composed of social
workers and supervisors, reviewed Sanchez's case because four of her
children already had been taken away.
The panel reviews the most serious cases. It twice recommended against
reunifying Sanchez with Savina, Rebecca and Roy.
Fresno County dependency court, which makes the final decision, didn't
decide on the case for several months because hearings were delayed
nearly a dozen times.
Sanchez used those months to take parenting and substance abuse
classes -- the same types of classes she had failed in the past.
Roy McBrearty, a social worker with a few weeks of experience, was
assigned to her. McBrearty declined to speak with The Bee.
There were conflicting signs as Sanchez moved through this process.
According to Savina's case file, Sanchez failed two drug tests -- both
for alcohol.
A county-contracted psychologist conducted a bonding study on Sanchez
and her children. The psychologist watched as they sang songs, played
with Lego blocks and cleaned up the play area when they were done.
The study found it unlikely Sanchez would change her life. The
psychologist told McBrearty that the study was "one of the worst" that
she had ever seen, according to the case file.
But Sanchez had completed a parenting class plus 13 weeks of
outpatient substance abuse treatment and 13 weeks of relapse
prevention treatment from the California Substance Abuse Institute.
McBrearty wrote that Sanchez had changed her life for the better when
the case finally went before a judge in April 2001.
"It appears that Ms. Sanchez will resolve the problems that led to the
removal of [the] minors," he wrote.
Judge Dennis Caeton agreed and ordered the eventual return of the
children to their mother.
Children and Family Services Department Director Zomalt, who was hired
by the county after Savina was returned to her mother, declined to say
why a social worker as inexperienced as McBrearty was assigned such a
complicated case.
Other department employees were involved with Savina's case, Zomalt
says: "No social worker works in a vacuum in this department."
Other county departments were involved, too, such as the District
Attorney's Office, which provides lawyers to represent the interests
of all children in foster care. Savina's lawyer, Patricia Phillips,
declined to talk about the case.
Zomalt says a failed drug test does not necessarily ruin a parent's
chance at reunifying with the child: "I can guarantee you that if a
dirty drug test justified removing children, we would have a lot of
children in the system. And the system isn't very good at raising
children."
Sanchez had visits with Savina from the start of foster care. Whitley
would bring Savina to county offices in downtown Fresno and Sanchez
would take Savina for several hours.
After the April 2001 court hearing, the length of Sanchez's visits
increased from a few hours to overnight trips. Whitley, who had wanted
to adopt Savina and called her Molly, says problems increased as well.
Whitley says she would send food with Savina on overnight trips: jars
of strained vegetables and fruit and a bottle of milk. The next day,
Sanchez would bring Savina back with the food unopened, the milk
curdled.
Savina returned with a sippy cup filled with soda.
"You're talking about a 7- or 8-month-old baby," Whitley says.
Whitley and her daughter, Jennifer Gochenouer, 30, say Savina started
returning from overnight trips with bumps and scratches. They became
so concerned that they took Polaroid pictures of the injuries.
The claims went both ways.
Sanchez took Savina to county offices on June 13, 2001, when Savina
had a bruise on her leg. Sanchez made county officials document the
injury, saying it happened on Whitley's watch. Whitley was later
absolved of any wrongdoing, but feared she could lose her foster-care
license and a week later asked that Savina be moved.
Jannita Hoff of Fresno provided a home for Savina for the next several
months.
Sanchez was granted custody of Savina, Rebecca and Roy on Oct. 24,
2001. In one of the department's last assessments, written that month,
social workers noted that Savina was beginning to talk, saying "mama"
and "dada." She walked and rarely fell. She waved bye-bye.
"She has a heart murmur," the assessment notes. "Other than that, she
is pretty healthy."
Savina went to Valley Children's Hospital on Dec. 6, 2001 for a reason
not documented in the case file. She weighed 19 pounds, 1 ounce.
County investigators twice visited Sanchez over the next six months
and found the three children healthy. According to the case file,
McBrearty met at least once with Sanchez and her three children over
the next six months and found Savina to be apparently healthy and
happy.
On May 10, 2002, the court's oversight of Savina ended and the county
no longer had authority to check on her.
On Oct. 20, 2002, Savina was taken to Saint Agnes Medical Center with
a broken arm, according to the case file. Savina was described in
reports as a "lovely child" who was healthy until her brother fell on
top of her and broke her arm.
She weighed 19 pounds, 5 ounces, 4 ounces more than about a year
earlier. An average child would weigh 23 pounds at age 1 and grow to
28 pounds by age 2, according to the county health department.
According to the case file, the next time county or medical officials
had contact with Savina was when paramedics responded to a 911 call at
Sanchez's house in central Fresno on April 28, 2003.
Dishes were piled in the sink. The refrigerator contained rotting
vegetables. Urine stained the floor.
Paramedics found Savina's emaciated body on a couch in Sanchez's
bedroom. Savina slept there because she didn't wear diapers and wet
the bed, Sanchez told authorities.
Savina's stomach was sunken, her ribs and spine showed and she had no
muscle tone. Her fingernails were long and ragged, with dried feces
under them.
According to the case file, Sanchez said she went to bed at 1 a.m. the
night before with Savina asleep on the couch.
Sanchez said she awoke at 7:30 a.m. to take Roy and Rebecca to school
and did not check on Savina. She returned, took a Vicodin and went
back to bed. Sanchez told authorities she was taking pain pills for a
back injury.
At 11 a.m., she checked on Savina and found the little girl wasn't
breathing. A teenage daughter who had gone to Sanchez's home instead
of school called 911.
Sanchez told authorities that Savina had been sick for three to four
days with nausea, vomiting and diarrhea, and was unable to keep fluids
down.
Sanchez, who was pregnant with her eighth child, said she couldn't
take Savina to a hospital because she had no transportation and no
phone. A social worker investigating the case noted that there was a
telephone at a market across the street.
It is unclear how the daughter called 911.
Social workers noted that Sanchez cried without tears during her
interviews. She took a drug test on April 30, 2003; it was positive
for cocaine.
Social workers placed Roy and Rebecca with Sanchez's sister, Korena
Sanchez, who owns a business with her husbandd and had taken in most
of Darlene Sanchez's other children.
Whitley, the foster mother from Coalinga, and Gochenouer learned of
Savina's death from the newspaper.
"She laid there all those months," Whitley said. "Was she wondering
where I was? Was she wondering why I didn't come to get her?"
Nancy Richardson, the longtime Fresno child advocate and one of the
authors of the most recent report on Fresno County's child protection
system, has no illusions about government care of children.
"There's nothing easy about this business," Richardson says. "You
notice you don't have the private sector begging with counties to do
this function.
"It is a high-risk enterprise."
The county's dilemma was revealed in the deaths last year of two
children.
With Savina, the county acted in what it thought was her best interest
by helping reunite her with her mother. Savina died.
The county acted in what it thought was Anthony Cortez's best interest
by taking him from his mother and placing him in foster care and
eventually in a group home. Anthony died.
Says Children and Family Services Assistant Director Huerta: "You make
your best judgment based on what you know, and even then you may be
wrong."
Until the late 19th century, government officials in the United States
dealt with the problem of abused and neglected children largely by
ignoring it. Children were considered property of their parents.
Government had no authority to step in.
The modern day child welfare system owes its birth to the Society for
the Prevention of Cruelty to Animals.
In 1874, a church worker in New York discovered a young girl named
Mary Ellen who was beaten and chained in a room by a couple who took
her from a charitable institution.
The worker attempted to get police to step in, but the officers said
they had no legal right to intervene. The worker turned to the SPCA,
stating Mary Ellen was an animal in need of protection.
The New York SPCA took the case to court and the girl was removed.
Other organizations followed suit and laws were written to protect
children.
The number of children in out-of-home placements in California soared
from 52,107 cases in 1988 to 110,244 cases in 1999. That number
dropped to 90,000 cases last year, according to the Child Welfare
Research Center at the University of California at Berkeley.
Fresno County saw out-of-home placements spike from 907 cases in July
1988 to 3,449 in July 1998. The number declined to 3,166 last July and
was about 2,700 in March.
State Department of Social Services spokeswoman Blanca Castro said the
rise was caused in part by the crack cocaine epidemic and
less-forgiving attitudes about the presence of drugs in homes with
children. Most children in foster care have been taken away because
their parents used drugs.
The increases strained departments attempting to handle so many
children.
Fresno County employs 703 people and spends nearly $54 million a year
on its Department of Children and Family Services, which includes what
used to be called Child Protective Services.
Sixteen children have died in the county's foster care program since
1997. Most died accidentally or of natural causes.
Some deaths have attracted considerable public attention. In June
2000, 10-year-old Melissa Renee Bradley died after she was forced by
her foster father to do deep knee bends in 100-degree weather.
Three months later, 22-month-old foster child Dexter Taylor Jr.
suffered severe head injuries and died after being beaten and shaken
by his foster mother's boyfriend.
Not all criticism of the department involved the deaths of children.
The department once housed some of its most difficult-to-handle foster
children in motels instead of home settings. The county stopped in
2001 after it became public knowledge.
It was into this system that Savina's life was entrusted.
Assembly Member Bill Maze is a harsh critic of it.
The Visalia Republican was in his first months in the state
Legislature last year when he read about the deaths of Savina, Anthony
and Christopher. He called for a state investigation into the deaths:
"I didn't see where there are public officials saying that we need to
get to the bottom of this."
Maze, whose district does not extend into Fresno County, withdrew his
inquiry in June. He and his staff have exchanged letters with the
department, and he doesn't like the answers he's getting: "I have been
stonewalled, roadblocked, and smokescreen after smokescreen has been
put up."
Maze says he hasn't been able to see the foster care files for the
three dead children. Legislators, like the public, need a court order
to get access to those records. In January, he proposed a bill to
allow legislative access to records on deceased children. The bill
failed, but Maze plans to reintroduce it next year.
Zomalt says Maze would be wise to work harder on solutions, such as
raising the amount of state funding for Fresno County social workers.
The county ranks second to last in the amount of state and federal
money it receives from the state.
"It's very easy for people to stand back and criticize what's being
done in a vacuum and then take no responsibility for helping to solve
the problem other than ordering another audit or another study,"
Zomalt says.
Zomalt notes that the death rate among the county's foster children
was lower than the state average. In Fresno County, four children died
in foster care last year and one has died this year.
The cluster of deaths within a month last year raised questions with
the county's foster care oversight committee, established as a
permanent committee by the Board of Supervisors after the "motel
children" issue came to light.
Zomalt created a three-member panel after the cluster of children's
deaths. Because of time constraints, the panel focused on the events
leading up to Savina's death. The panel includes two members of the
oversight committee, Richardson and Polly Franson, plus Karen Rea, the
Children and Family Services Department's quality assurance manager.
Last month, the panel released an eight-page public report with
suggestions to improve the system.
The report describes an "incredibly complicated" foster care system
where it is too easy for employees to become absorbed by day-to-day
tasks and lose sight of goals.
It says the county lacks the habit and mechanisms to critique "the
collective product of their work, even when a child dies," and it
makes several recommendations:
Only employees with appropriate skill and experience should handle
complicated cases such as Savina's. New social workers need to be
trained and mentored.
Workers within the department should talk frequently. Where substance
abuse is an issue, substance abuse specialists need to be involved
throughout the case.
Supervisors need to speak with foster parents and other providers as
cases progress rather than relying solely on social workers.
Supervisors need to be "trained, competent, compliant and
accountable."
Substance-abusing parents who reappear in the system should not be
enrolled in the same treatment programs they already have participated
in.
Staff, foster family members and other care providers need to be told
when a child dies. They should get a chance to grieve and discuss what
happened.
The panel produced a second internal report on Savina's case, but the
department would not release it because it names specific people, such
as other siblings.
Richardson, who wouldn't talk about specifics of Savina's case, said
the public report is another in a long line. The recommendations in
many are strikingly similar: Better training, better follow-through,
lower caseloads.
On April 29, 2003, the day after Savina's body was found, county
supervisors embraced a new initiative they hope will lead to lasting
foster care reform. It is called Family to Family and shifts the
emphasis of social workers from day-to-day tasks to results.
Board Chairwoman Anderson, who also serves on the oversight committee,
initially was skeptical. Now she believes the initiative can make a
difference.
"For the first time, I think people are being really honest about the
issues and the problems we have to fix. But it's kind of like turning
around a herd of elephants."
The initiative is a nationally recognized system developed by the
Annie E. Casey Foundation, a nonprofit foundation established by the
founder of United Parcel Service. Twenty-three of California's 58
counties use it.
Andrea Sobrado, the county's Family to Family coordinator, said the
initiative focuses on goals that can be measured from year to year.
These include taking fewer children from their families, putting fewer
children in institutional care and shortening stays in foster care.
County officials note that the county's involvement with Savina's case
ended more than two years ago. His department, Zomalt says, is fast
entering a new era.
County officials say they are embracing the panel's frank critique.
Yet, they add, they cannot guarantee there will be no more tragedies.
Says Zomalt: "We're not under the illusion that we can be out there in
every home with every kid at all times to ensure their parents or
foster parents or relatives won't harm them."
Darlene Sanchez and Savina's father, Roy Gonzales, held the little
girl's funeral at St. Peter's Cemetery west of Fresno on July 25,
2003, on a hot summer day cooled by the shade of pine trees.
Before the ceremony, as people arrived at the cemetery, Sanchez walked
away from her daughter's pink casket, dropped to the ground and
wailed. Someone rushed to comfort her.
About 30 mourners sat around Savina's casket, which was decorated with
a bouquet of white and peach flowers.
Pastor Juan Gomez spoke in Spanish, then English, while a Mexican band
played in the background.
"There might be someone here who needs to ask for forgiveness," Gomez
said. "I don't know the case. I don't know the cause of death. But I
do know God is here today."
After the service, Sanchez took a handful of dirt and tossed it on her
daughter's casket.
She walked over and pulled a blossom from the bouquet, kissed it and
tossed it into the grave.
Roy Gonzales, who was in Wasco State Prison on a probation violation
when Savina died, sat on a folding chair, holding his head as family
and friends left. When only cemetery workers remained, he picked up a
shovel and started burying his daughter.
Four days later, a memorial service for Savina was held at New Hope
Community Church in Clovis. Among those attending were Whitley and
Savina's other foster families.
Darlene Sanchez's sisters -- Korena Sanchez and Sylvia Gist -- and
many of Savina's siblings also attended.
Whitley, Korena Sanchez and Gist hadn't been invited to the funeral.
Darlene Sanchez has feuded with her sisters because Korena Sanchez is
raising many of her children, the sisters say.
The church was decorated with pink and white balloons. An arrangement
of flowers sat by a large picture of Savina.
After the service, Pastor Tim McLain Rolen asked the people to take
the balloons that were tied to the pews and walk outside. Rolen
gathered the group in a circle and said a prayer. Then the group
released the balloons.
"Just as, for two years, she added color to our world, we add color to
the heavens," Rolen said.
The mourners walked into annex building, ate cake and comforted one
another.
Sara Glazebrook -- sister-in-law of Nancy Glazebrook, one of Savina's
foster mothers -- encouraged the others not to give up.
"I know this is difficult, but don't let [Savina's] death be in vain,"
Sara Glazebrook said. "Don't give up -- you have to keep taking the
next child from the county no matter how angry we are now."
Korena Sanchez has kept Darlene's son, Roy, but turned over Rebecca to
another foster family. She says she already is raising too many of her
sister's children.
-------------------------
A good friend will come and bail you out of jail . . . but, a true friend will
be sitting next to you saying, "Damn . . . that was fun!"
-----Unknown
I guess with a baby, who's to stop you? You can use it as a nickname:
Instead of shortening Savina to Savvy or Vinny or whatever, you just
use a different name, like Molly.
Though I suspect in this case, it was because she hoped to adopt the
child, and would have changed the name legally had she been able to
adopt her.
Rupa