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 AB8, 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.
Conclusions
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.
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
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.
