Newly Released Documents Show that 4-Year-Old Noah Cuatro Died Despite Known Risk  

A photo of Noah Cuatro, who died in early July in the Antelope Valley area of Los Angeles County. Photo: KABC.

On Wednesday evening, Los Angeles County’s Department of Children and Family Services (DCFS) released heavily redacted agency documents related to the July death of 4-year-old Noah Cuatro. 

Key among the documents are four “risk assessments” and five “safety assessments” conducted by county child welfare caseworkers between 2014 and as recently as June of this year, only weeks before Noah died. 

To help determine the risk of subsequent maltreatment in child abuse investigations, DCFS, like many other agencies across the country, uses a risk assessment tool called Structured Decision Making, or SDM. Child welfare workers fill out a computer-based questionnaire, which then spits out a risk score. Another similar questionnaire helps to decide whether it is safe to keep a child in the home. 

In the case of Cuatro’s family, all four risk assessments ranked high or very high. More importantly, SDM instructed the caseworker to “promote” the case in all instances, ensuring a higher level of scrutiny ranging from voluntary services to court oversight. Given the fact that Noah spent time in foster care, it is clear that DCFS did heed these warnings in some cases. 

As recently as May of this year, DCFS rejected the tool’s recommendation to promote the case. The reason, according to the document: “Family is in an already open DCFS case. Allegations cannot be verified.”

More chilling still was the last SDM score entered on June 18, less than three weeks before Noah died. The risk was “very high” according to SDM, and the caseworker notes read: “There are current concerns for the mother’s mental health.” 

On July 5, Noah’s parents called 911 claiming he had drowned in the pool of their Palmdale apartment complex. The next day he was pronounced dead. But, the Sheriff’s Department stated that the boy’s injuries were inconsistent with drowning. In May, the juvenile court ordered Noah removed from his parent’s home. The reason why that order wasn’t carried out remains a mystery. 

How the county uses SDM was also a subject of scrutiny in the 2016 death of Yonatan Aguilar, an 11-year-old whose risk scores also suggested escalating involvement by DCFS.  

2017 report by the county Office of Child Protection resulting from the Aguilar case recommended that DCFS should revise its policies:  

“DCFS’ policy on how to respond when an SDM risk level is high or very high, but referral allegations are unfounded or inconclusive, should be revised to include case promotion and the appropriate level of manager approval needed prior to referral closures, as well as further assessment of the family’s needs for connections to appropriate voluntary services and/or community supports,” the report reads. 

Of the five safety assessments conducted in Noah’s case, three came back “safe,” and the first two in 2014 and 2016 were deemed unsafe. 

The redacted records do suggest that at various points in this family’s history, DCFS was concerned enough about the home to remove some or all of the children from it. A 2014 safety assessment noted “serious physical harm” to a child in the home – while the assessment notes do not include a reference to removal, the following box is checked:

 “One or more safety threats are present, and placement is the only protecting intervention possible for one or more children.”

 A safety assessment from November of 2016, which did describe the home as safe, also noted the removal of two children who were placed in a home managed by a foster family agency. 

And in April 2019, just months before Noah’s death, a report notes that at least one of the Cuatro children was removed from the home, and then returned.

“The minor was recently released back to his parents through court and the family is doing all they can in order to move forward with this case closing,” the April report states. 

Next week the County Board of Supervisors will consider a DCFS request to increase funding for Structured Decision Making by $128,000. 

“The recommended action will improve the accuracy, consistency and equity of caseworker decisions,” the DCFS letter making the request states.

This story originally stated that the 2017 report on Structured Decision Making was spurred by the death of 10-year-old Anthony Avalos. It was in fact triggered by the death of 11-year-old Yonatan Aguilar. The story has been updated to correct the error. 

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