A center for kids with severe behavioral and psychiatric problems was ordered to close its doors in 2017 — but not until 243 reports of suspected abuse and neglect were filed in the span of a year, according to an investigation released Tuesday by the state’s child protection ombudsman.

The delay allowed children and teens to suffer repeated abuse, often committed by staff members who had faced previous accusations. The allegations involved aggressive restraint tactics, bruises and lack of food, the review found.

The last 37 children and teenagers who lived at El Pueblo Boys & Girls Ranch left for foster homes or returned to their parents almost two years ago, and the 56-acre ranch remains closed. But the new report from the state’s independent monitor of the child welfare system focuses on this question: Why did it take so long?

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Seven counties received the 243 reports of suspected institutional abuse and neglect at El Pueblo, with the vast majority — 219 — going to Pueblo County. But Pueblo County caseworkers determined that most of them were unfounded and “screened out” without further investigation.

Just 12 percent of the calls were assigned to a caseworker for further review. This means the reports of abuse at the center were screened out at a rate three times higher than reports of abuse or neglect within families.

Pueblo County caseworkers who were interviewed by the child protection ombudsman’s office said they thought a different agency, a 10-person state team responsible for reviewing residential child care facilities, would look into the allegations. That group, part of the state division of child welfare, eventually shut down El Pueblo, but not until abuse and neglect was allowed to continue for at least a year, the investigation found.

“It’s shocking,” said Stephanie Villafuerte, the state’s child protection ombudsman. “One thing we learned is how insular the system is, and because of how insular it is, how little exposure the problems will get.”

Most of the allegations of abuse and neglect were self-reported by center staff, who are required by law to notify the county when a child is injured or alleges a sexual assault.

In one case, a child’s arm was reportedly twisted behind his back and a video of the incident was deleted. In another, a girl was able to escape the ranch and board a train. She told authorities she was starving and that kids at the center bullied each other.

Pueblo County received two reports alleging a boy was repeatedly restrained by staff. The county screened out both. Yet when the state team reviewed the case, team members discovered the boy had been repeatedly injured in assaults by other youth at the center and during physical restraints by staff.

In one instance, a staff member stopped the boy from eating from a plate of food that he had gotten from a trash can. The boy said he was still hungry and “upset the kitchen was not providing second servings,” the ombudsman wrote.

Medical records showed the boy had entered the center at a healthy weight and lost 20 pounds within 10 months of living there.

County, state both thought the other would handle it

Calls to Pueblo County that concerned possible licensing violations — including that children were unsupervised and staff were subduing them with force — were screened out under the assumption that the state team had jurisdiction. However, Pueblo County did not notify the state team of the calls, nor did they enter them into the statewide child welfare computer system, the ombudsman found.

At the same time, state team members said they did not review several concerning incidents identified during on-site visits because they thought the county would look into them.

In the year before the privately run nonprofit center was shut down, the state team notified Pueblo County about seven reports of suspected abuse or neglect at the center. The county screened out all seven.

The decision not to pursue any of the allegations is what prompted the state team to initiate its own reviews of the center and ultimately what led to its closure. The state child welfare department said it has worked to improve the system in the nearly two years since the center was shut down.

Lee Hodge, deputy director of Pueblo County Human Services, said caseworkers frequently visited foster children living at El Pueblo and that children in residential facilities typically have multiple eyes watching out for them, from parents and caseworkers to staff and guardian ad litems. “I think that’s all of our responsibility,” he said.

Reports were screened out because they did not meet the legal definitions of abuse and neglect, although they might have met the legal definitions for licensing violations, he said. Hodge also noted that the 12 percent “screen-in” rate was not too far off the statewide average for looking into allegations at institutions, which is 13 to 17 percent.

Pueblo County officials are involved in conversations with the state to improve the system. “All of us want to get better,” he said.

All of the recommendations in the ombudsman’s report were targeted at the state, not Pueblo County.



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The disconnect between the county child welfare department and the state team was a focal point of the ombudsman’s investigation. In the report, the ombudsman recommended the state child welfare division — part of the Colorado Department of Human Services — revise its two-step system for keeping kids safe at residential facilities.

The current system puts county departments in charge of assessing abuse and neglect allegations at the centers, with the state team to follow up regarding licensing issues after the county has completed its case-by-case reviews. That framework allows for children to “continue residing under the same conditions for weeks or months” before the state team addresses safety concerns, the report said.

The ombudsman found that youth living at El Pueblo remained under the care and supervision of staff who had been accused of abusing them. In one case, a youth was reportedly dragged across the carpet by two staff members, resulting in rugburns on his face. The same two staff members were accused of similar abuse about one month prior.

And in another, a 13-year-old girl said she was sexually assaulted by another youth after the two left the ranch without permission. Both teens said they were gone for about two hours, yet staff had checked them off as in their beds. It took nearly six months after the alleged assault was reported for El Pueblo to submit an acceptable response to the state team’s corrective action plan.

That delay is unacceptable, Villafuerte said.

“It should be a privilege to conduct business in Colorado. It’s not an entitlement,” she said, noting that while it’s true that businesses are entitled to due-process before their license is revoked, it’s more important that children are safe.

“What I would like to see is a paradigm shift: How do we just protect kids and work systems around that? If we keep saying contract holders have due process, that means kids will get left in harm’s way like in this case for 12 months.”

10 people to license 230 facilities

The report also recommended the state expand its state team. The 10 people are charged with licensing and monitoring about 230 facilities across Colorado.

In their official response to the report, state child welfare leaders said they would seek additional funding from the state legislature to expand the team and agreed to review policies regarding the review process. Following the closure of El Pueblo, the state team changed its policy to begin reviewing reports of abuse at residential treatment centers that have been screened out by county child welfare departments.

The ombudsman’s investigation also hammered the state for not allowing parents, caseworkers or the public in general to find out whether a residential treatment center is safe. The lack of transparency “stands in stark contrast” to other facilities licensed by the state human services department, the report said. Parents can look up daycare centers on a public website that lists licensing violations and corrective action plans, for example.

“El Pueblo represents a worse-case scenario for children and youth. If the issues in this report remain unaddressed, that scenario has the potential to repeat itself,” the report said.

The center lost its license, the kids were moved out, the case is closed, and everyone acts as if they “should go home and say the system worked well,” Villafuerte said. “Well, it didn’t. That’s the ultimate question we should be asking ourselves.”

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