The independent review commissioned by Kern County following the death of eight-year-old Genesis Mata found no substantial systemic failures within the County’s child welfare services, but concluded that the department must make improvements to staffing, casework, family engagement, and organizational practices to better protect children.
The findings were presented during Tuesday morning’s Kern County Board of Supervisors meeting by the San Diego State University (SDSU) Social Policy Institute (SPI) and concluded that Kern County’s child welfare outcomes are “generally on par” with statewide and national performance standards.
Despite this, the report identified five major areas requiring continued investment and improvement, including workforce development, social work practices, family engagement, continuous quality improvement, and coordination among agencies.
The review also highlighted challenges unique to Kern County that affect how families access services.
According to the report, poverty rates are significantly higher in Eastern Kern than in the rest of the county, creating additional barriers for families already navigating the child welfare system. Reviewers noted that many communities face limited transportation options, fewer behavioral health providers, housing shortages and reduced access to community-based services, all of which can make it more difficult for families to receive support before crises escalate.
The report concluded that those regional differences underscore the need for strategies tailored to individual communities rather than a one-size-fits-all approach to child welfare services.
Human Services Director Lito Morillo opened Tuesday’s presentation by acknowledging the tragedy that prompted the review.
“Whenever a child dies from abuse or neglect, it affects everyone, most importantly the child’s family and loved ones, but also the social workers, supervisors, law enforcement officers, medical professionals, community partners and countless others who dedicate their lives to protecting children,” Morillo said. “These tragedies remind us that behind every case file is a child, a family and a community changed forever.”
Morillo said the County commissioned the review to examine the department’s operations, decision-making, supervision, and policies; not simply to look at a single case.
“We also recognize that this tragedy has shaken the public’s confidence in Child Protective Services (CPS),” Morillo said. “Many members of our community have asked difficult questions and have expressed the belief that CPS should have prevented this child’s death.”
SPI’s assessment relied on a broad review of the county’s child welfare system.
Researchers examined more than 350 documents, interviewed 55 individuals, conducted 16 focus groups involving more than 100 county staff and community partners, hosted eight community listening sessions, reviewed dozens of child welfare cases and referrals, and surveyed both county employees and community members.
SPI Co-Director Lori Clarke said reviewers were given unrestricted access to county records and personnel while conducting what she described as a systems-focused assessment.
Rather than assigning individual blame after a critical incident, Clarke said the review used Casey Family Programs’ Safety Science Framework, which evaluates the broader systems that influence child welfare outcomes.
Clarke said their review found no substantial systemic failures that would compromise the department’s ability to fulfill its child welfare responsibilities. Reviewers also found no evidence of the type of organizational failures that have resulted in state or federal intervention in other jurisdictions.
Clarke emphasized that distinction during Tuesday’s presentation.
“What I mean by substantial failures are the kinds of negligence, the kinds of willful neglect of improvements, of needed professional and legal standards that have led in other jurisdictions to the state taking over the system or the federal government taking over the entire state,” Clark said. “So we’re looking at a matter of scope and type and intent behind them. So for clarity, that was not found here.”
Rather than focusing solely on responding to abuse after it occurs, reviewers recommend Kern County continue shifting toward what they describe as a “Wellness System of Care,” an approach that emphasizes prevention by strengthening partnerships among schools, health care providers, behavioral health agencies, community organizations and other family-serving systems. The report argues that improving child safety requires addressing the conditions that place families at risk before they enter the child welfare system.
Throughout the presentation, SPI representatives repeatedly identified workforce challenges as the foundation for many of the department’s broader issues.
“We’re talking about better tools for social workers, better training, better supervision and overall more time to be able to be spent with children and families so that our workers don’t have to choose between documentation and compliance with timelines or spending the time,” Clark said. “Those workforce process improvements are geared toward making it possible to do both.”
The assessment also notes that Kern County’s size and demographics present unique challenges. Stretching across more than 8,000 square miles, the county includes densely populated urban areas alongside remote rural communities where families often travel long distances to reach health care, behavioral health and social services. Reviewers said those geographic realities contribute to disparities in service access and require flexible approaches to supporting children and families across the county.
Although several public speakers thanked the county for commissioning an independent review, many said the report should serve as a starting point rather than a conclusion.
Former foster youth Nadine Escalante questioned how the county plans to keep community members involved during implementation.
“We want to make sure the community is involved in this,” Escalante said. “Because as an advocate, I talk to these families, I talk to these children, and their voices were heard.”
Former Kern County Child Protective Services social worker Aureli Villazana urged county leaders to publicly identify what constitutes a safe caseload for social workers.
“What is the max caseload a Kern County CPS worker can safely carry?” Villazana asked. “We have numbers for everything else. We don’t have that one. And that one matters. This job is not paperwork. It’s children’s lives.”
Former foster youth Alejandro Rocha also questioned what practical changes social workers would experience and suggested exploring new tools that could help identify high-risk cases sooner.
Supervisor David Couch asked how the county plans to move from recommendations to implementation.
Clarke said implementation teams will prioritize each recommendation, establish timelines, involve community partners and residents, and provide ongoing public progress reports as changes move forward.
Morillo also announced the department will hold a community forum July 30 at the Boys & Girls Club and said people with lived experience will continue helping shape future policy and procedural changes.
Questions also arose about whether artificial intelligence could help reduce administrative work for social workers.
Morillo said the department is exploring AI as a tool to improve efficiency, but not replace professional judgment.
“Social work, by its very nature, requires people,” Morillo said. “What I was really mirroring was just the fact that AI could be used as a tool… If you think about taking a referral and having that already documented for you, and then the social worker looking at that referral… it’s going to be beneficial.”
Morillo closed his opening remarks by emphasizing that the report marks the beginning, not the end, of the county’s work.
“Every policy we revise, every process we improve, every training we develop, and every conversation we have ultimately answers one question: How does this make children safer and families stronger?” he said. “This report’s not the end of the process. It’s the beginning of the next chapter in our journey to becoming an even stronger and much more improved child welfare organization.”
Following public comment, the Board voted unanimously to approve the staff’s recommendation.
