This summer, a 4-year-old boy named Noah Cuatro was allegedly tortured and killed by his parents in Palmdale, a high desert exurb of Los Angeles County. The tragedy is still sending shockwaves through the county’s $2.9 billion child welfare agency and local government.
Interviews with multiple sources inside the Department of Children and Family Services (DCFS) and previously unseen documents have revealed that less than two months before his death, the two social workers with the most intimate knowledge of Noah and his turbulent home life pleaded that he be taken from his parents – only to be shut down by their managers.
Maybe harder to reconcile is just how close DCFS came to saving the boy. Despite requesting and being granted a warrant to remove Noah from his parent’s home in May, sources say two high-level administrators decided not to carry it out. Noah died less than two months later – and his parents have since been charged with his murder.
Of the nearly 5,000 warrants to take children from their homes issued by the juvenile court in the first half of 2019, only two were not carried out. Noah was one of those two children – putting an exclamation point on how extraordinary the decision to ignore Noah’s removal order was.
Despite this, a county report released in September argued that the “basis for [Noah’s] removal was sketchy” and that DCFS acted appropriately by not taking Noah away from his parents.
The decision to leave Noah at home came at a May 22 meeting in DCFS’ Lancaster Office, an outpost of the vast 9,000-person bureaucracy, which has been shaken by eerily similar alleged killings of children by their own families in recent years.
During that meeting, the two workers who had carried Noah’s case for more than three years combined expressed their deep, visceral fear that something terrible would happen if Noah were left with his parents. But, three other DCFS employees in the room – a child abuse investigator, her supervisor and a high-level manager who had recently been rotated into that position – argued that insufficient evidence trumped the gut instinct of the worried social workers. Noah would stay with his parents.
“I have real concerns that the voices of those trying to protect Noah were not listened to,” said David Green, a veteran child welfare worker and a leader in the local union that represents them.
Given the highly sensitive nature of this case, The Chronicle of Social Change is not disclosing the names of the workers involved. Instead, they will be described by their roles and connection to Noah.
May 15: A Family in Prolonged Crisis
On May 15, the “continuing services” social worker handling Noah’s case filed a petition with L.A. County’s juvenile court to allow her to remove the boy from his parents. Unlike “emergency response” workers who primarily investigate allegations of child maltreatment, continuing services workers will stay with a child’s case for months and even years.
An affidavit submitted to the court by Noah’s social worker described why the little boy had spent two stints in foster care. His first entry was due to allegations that his mother, Ursula Juarez, had fractured the skull of her own baby sister by throwing her in the crib while nine-months pregnant with Noah herself; the other was because of “medical neglect.”
“Noah had gained no weight in 7 months,” the social worker wrote.
She was also concerned about allegations that Noah had “night terrors,” his “butt hurt,” and that his “father hits and curses at him.” Bruises on the boy’s back and arms were explained away by his mother Juarez’ claim that Noah had fallen off a bunk bed, leaving him “out of air.”
During a mid-April investigation at Noah’s home, his social worker took photos of the bruises and interviewed the little boy alone. When asked “what happened when he does something wrong,” Noah said, “’I get hit.’” When asked where, the boy said, “’I do not get hit.’”
“During the interview the minor appeared to be answering his question [as if]… scripted or coached,” Noah’s social worker wrote. “Noah kept stating that he loved his mother and father and that they take him to the park and Knott’s Berry Farm and that mother buys him gifts and father gives him warm showers.”
While a doctor would ultimately say that Juarez’ story, echoed by Noah, about the bruises was “plausible,” his social worker had other concerns. Juarez and Noah’s father, Jose Cuatro, had repeatedly “lied” about where they lived.
And, the social worker believed that Noah’s father suspected the child was not his. She wrote that Cuatro believed, contrary to any disclosed medical diagnosis, that his young son had sickle cell anemia – “a disease that black people get, so he thought Noah’s father must have been black.”
“The Child needs to be removed … to ensure the child’s safety and to protect the child from the endangering or detrimental conduct of the parents,” Noah’s social worker wrote in the conclusion of her petition.
The day she filed it, Steven Ipson, a commissioner with the dependency court, signed the order authorizing the boy’s removal. Ipson had presided over Noah’s case as he bounced in and out of foster care for years – suggesting he understood the context of the warrant request well.
But disagreements between the emergency response workers charged with investigating Noah’s abuse, and the continuing services workers who had been carrying Noah’s case for years, erupted in the Lancaster office.
The continuing services social worker’s gut instinct told her to take the boy away from his parents. She wasn’t alone.
The Frightened Human Services Aide
On May 15, Noah’s maternal great-grandmother, Eva Hernandez, called the DCFS-operated child abuse hotline alleging that Noah’s maternal aunts and an uncle had told her that the boy had “woke up screaming in the middle of the night,” and had told his uncle that “his butt hurt.” All would later “unequivocally indicate” that the allegations weren’t true, according to the Office of Child Protection Report.
In response to this second allegation involving sexual abuse, the Department of Children and Family Services dispatched two workers: an emergency response investigator who had been assigned to Noah’s case less than a month before, and a human services aide. So-called HSAs are the lowest rung of the DCFS totem pole, serving as assistants to social workers and supervisors.
The HSA was not new to the Cuatro family: from late 2016 through 2018, she had been Noah’s continuing services social worker. But she opted to “self-demote” because she fell physically ill, at least in part, because of her fears for Noah’s safety. During her two years as Noah’s social worker, she filed repeated letters to Judge Ipson expressing her growing fears.
In a letter she wrote in June 2016, during Noah’s second stint in foster care and while he was living with his great-grandmother Hernandez, the former continuing services social worker described how the boy feared spending the night with Cuatro and Juarez: “Noah will cry for 15-40 minutes stating that he does not want to visit his parents,” she wrote.
In August 2018, just weeks before his fourth and last birthday, she recounted a conversation with the boy in another letter to the court.
HSA – Do you want to visit with mommy and daddy this weekend?
Noah – shook his head.
HSA – What do you mean?
Noah – It’s scary.
HSA – What is scary? The House? (Noah shook his head) [Your brother]? (Noah giggled and said no). Mommy (Noah nodded) What about daddy? (Noah nodded and said yea)
Maternal great-grandmother Hernandez painfully recalled Noah’s increasing anxiety about being sent home.
“He would beg not to go to parents,” Hernandez said between tears during an interview. “He would pull my face and tell me ‘Grandma, look at me, look at me. Please don’t make me go over there.’”
Trying to make Noah understand how powerless she was, Hernandez told him, “It’s the social workers, it’s the judge.”
But the little boy could not understand. “He says, ‘No Grandma, you are making me go.’’’ Recalling the scene, Hernandez said: “It just makes me crazy.”
The Office of Child Protection (OCP) report from September, which absolved DCFS of wrongdoing in Noah’s case, mentioned the HSA’s deepening worries. During a May 9 discussion with the emergency response worker investigating the bruises on Noah’s back and arm, the aide said, “she had always had concerns for Noah, was opposed to his return home, and felt that the parents are habitual liars who present well.”
She feared that he was a “targeted sibling.”
May 20: A Vignette from Noah’s Last Days
On May 20, the emergency response investigator and the HSA left the Lancaster office to investigate the May 15 allegations of sexual abuse and domestic violence.
A write-up of the aide’s impressions from that visit – the last time she would see Noah – paints an inconclusive but disturbing picture.
After searching for the family at an apartment complex in North Hills in the San Fernando Valley, the emergency response investigator and the HSA were told the family had moved to Palmdale.
There the workers found the two parents, Noah, his older brother and his younger sister in a bare one-bedroom apartment containing only a TV and a “storage tub bin” placed on the carpeted floor.
The emergency response investigator took mother Juarez into the bedroom to interview her alone.
Noah asked the HSA, who he’d known for much of his short life and was happy to see, to play with him on the floor. Noah’s father opened the storage tub and said, “here, grab some toys so you can play.”
While playing with Noah, the aide noticed “a circular spot along his upper left cheekbone area … approximately the size of a half-dollar American coin.”
When asked what had caused the mark, Noah called it a bug bite. But father Cuatro interjected, “No, remember you fell, we took you to the doctor and they gave us ointment.”
The pre-school-aged boy’s unusual behavior during their visit was detailed by the human services aide, who wrote: “Randomly in the chaos of the children laughing and running in and out of the bedroom, Noah would run up to the H.S.A. and try to whisper statements and run away. … ‘I act up,’ he whispers. ‘They feed me a lot [name of HSA] – they take good care of me [name of HSA] – they love me [name of HSA] – they take me places – I am going to have a baby brother.’”
After the emergency response investigator finished her interview with Juarez, she and the HSA took Noah into the bedroom to interview him alone. When the aide asked Noah what he meant by “I act up,” her notes recount, “Child’s eyes widen, he shook his head as he stated, ‘I don’t act up.’”
Sensing his distress, the aide drew a house and “a happy face, sad face, crying face and an angry face. When asked how mommy and daddy were, he began to point in the direction of angry, then corrected his direction to happy.”
The HSA wrote, just as Noah’s last social worker had in her warrant petition to the court only days before, that the little boy’s “responses throughout the visit appeared coached.”
When the emergency response investigator asked Noah’s mother, Juarez, to join them in the bedroom so the social worker could conduct a “body check” of Noah, she found no bruises.
But when the human services aide asked Juarez about the mark on Noah’s face, her story was different from that of father Cuatro and the little boy.
“Oh we were at a party and some kids were playing,” Juarez said, according to the HSA’s write up. “Children had rubbed an ice cube on Noah’s face with salt.” She said she had been putting “a special ointment” on the mark.
“As mother sat on the floor,” the aide wrote, “H.S.A observed mother cradling the bottom of her belly with her hands.”
On June 6, less than three weeks later and after repeatedly denying to social workers and investigators that she was pregnant, Juarez gave birth to a baby boy – her fourth child.
On June 28, the emergency response investigator visited the family’s Palmdale apartment. According to the Office of Child Protection report, “Noah was described as being in good spirits and reported that he was doing well.”
A week later the boy was dead.
May 22: A Divided Room
Two different social workers with intimate knowledge of the Cuatro family – Noah’s last continuing services social worker, and the one who had opted to become a human services aide – had urged removal.
And, sources say, their supervisor agreed with them. It was this continuing services supervisor who had instructed Noah’s current social worker to request the warrant for removal.
But the effort to remove the young boy would soon be stopped. The same day the boy’s social worker asked the court to remove Noah, a high-level manager tried to rescind the petition and decided to take Noah’s case away from the social worker.
According to a source with knowledge of the meeting’s details, the “assistant regional administrator” overseeing the emergency response workers involved with Noah’s case, “stated that [Noah’s social worker] was to withdraw the warrant and that they wanted [her] off the case and a Spanish speaking worker put on the case.”
When that administrator realized that commissioner Ipson had already signed the order to remove Noah, she told another high-level administrator and the continuing services and emergency response staff, “Do not serve the warrant.”
A week later, on May 22, a meeting was held to decide once and for all what to do with the removal order. Attending the meeting were the two workers that had carried Noah’s case for more than three years, along with the emergency response investigator and her supervisor.
The acting assistant regional administrator, who had had been present at the May 15 meeting, would be the one to make the final decision on May 22. She had been thrust into that critical role only weeks before, according to sources, an apparently commonplace practice in DCFS’ rangy bureaucracy.
Noah’s first social worker, now a human services aide, stated “her concerns about Noah and [said] there was a mark on his face that she was concerned about,” according to a source.
The supervisor who had told Noah’s last continuing services social worker to seek removal was on leave, and did not attend the meeting. She has since resigned from the department, according to multiple sources.
If the supervisor had been at the meeting, she would have supported Noah’s removal – sources said that before she retired, she had sent an “email expressing concerns over [the] child” to others involved in the case.
That left the two workers with the most knowledge of the family to defend their conviction that Noah should be taken from his parents. But another source with direct knowledge of the meeting said that they “couldn’t get a word in edgewise.”
At one point, a source says, Noah’s last social worker suggested that the acting administrator and the emergency response staff hadn’t read her petition before deciding to leave Noah with his parents.
DCFS’ director, Bobby Cagle, said in a statement that management acted appropriately by not removing Noah. A decision that was affirmed by the Office of Child Protection report as well as the fact that when the juvenile court was notified that the warrant hadn’t been carried out, “it did not order the Department to detain [Noah],” Cagle said.
“Like many of the cases that come to our attention, this case in particular had a very complicated history. A removal warrant is not an order to remove a child, but rather, it is permission to remove a child. Following the court granting DCFS permission to remove Noah, social workers engaged in appropriate consultation with their managers and a decision was made that further investigation was needed to better inform whether or not to remove him.”
July 5: Noah’s Parents Call 911
On July 5, Noah’s parents called 911, saying that Noah had drowned. But when Sheriff’s deputies arrived they saw bruising on the boy’s body, and would launch a homicide investigation soon after. Noah was airlifted by helicopter to Children’s Hospital, where he died the next day.
On September 27, Sheriff’s deputies arrested Ursula Juarez and Jose Cuatro. Three days later, the District Attorney’s office filed charges of murder and torture against the couple.
The DA’s charges suggest that father Cuatro beat Noah severely, and that Juarez “permitted that child to be injured and harmed and that injury and harm resulted in death.”
For a period after Noah’s death, the front-line staff involved in his case – the human services aide, Noah’s last social worker and the emergency response investigator – were placed on “desk duty,” according to a source in the Lancaster office*.
Multiple sources say that Noah’s last social worker has broken down at the office and has been heard crying: “They let my baby die.”
NOTE: An earlier version of this story asserted that the front line workers involved in Noah’s case were current placed on “desk-duty.” This has been updated to reflect that they are no longer on “desk duty.” The term “desk duty” should not be construed to suggest that the workers were given any formal discipline.