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.