The 5-year-old girl was found dead in the bathtub with shallow water framing her cherubic face and open eyes.
The state Department of Children and Family Services had conducted two abuse investigations into Verna Tobicoe's Southeast Side home in the months before her death in May 2015. The agency also had hired a nonprofit group to make frequent visits and conduct safety checks on Verna and two siblings.
Even as Verna was hospitalized with a broken arm and her older brother repeatedly appeared at hospital emergency rooms or doctors' offices with suspicious lacerations and bruises, a caseworker for the nonprofit organization filed cheerful reports saying the kids were safe.
And then 44-pound Verna became part of a growing pattern of similar fatalities: She was one of 15 Illinois children to die of abuse or neglect from 2012 through last year in homes receiving "intact family services" from organizations hired by DCFS, a Tribune investigation found.
There was only one such child death under the intact family services program during the previous five years from 2007 through 2011, according to DCFS records released to the Tribune under the Freedom of Information Act.
The mission of intact family services, which roughly 2,700 children are receiving statewide, is to offer counseling, resources and oversight to keep families together, instead of putting children through another trauma by removing them from the home and placing them with strangers.
The spike in deaths began in 2012 after DCFS completely privatized the program, putting the care of families in the hands of nonprofit groups but doing little to evaluate the quality of their work, give them guidance and resources, or hold them accountable when children were hurt or put at risk, the Tribune found.
The girlfriend of Verna's father is now awaiting trial on first-degree murder charges in the girl's death. Authorities found lacerations in Verna's liver and intestines as well as a skull fracture and bruises across her body from repeated blows. Lisamarie Villasana, 29, has pleaded not guilty and told police that Verna hit her head after slipping on spilled Gatorade.
The agency was rattled by a similar death in April, when 17-month-old Semaj Crosby was found dead in her Joliet Township home after DCFS had conducted more than 10 abuse investigations into the family and used the intact family services program to send a caseworker for periodic visits.
Illinois' new child welfare director, Beverly "B.J." Walker, said she was alarmed by the Tribune's finding on the surge of child fatalities in intact family services cases as well as by a sharply critical report from the DCFS Inspector General on Verna's death.
Walker recently asked her staff to provide reports on the abuse or neglect of any child in the intact services program and said she was shocked to discover that at least 10 percent of children were reportedly mistreated while receiving those services. "That's very high. ... I can tell you this, it happens too much," Walker told the Tribune.
The Inspector General's report, which has not been made public but was examined by the Tribune, determined that DCFS conducted cursory and ineffective investigations into a series of abuse allegations in the months before Verna's death. DCFS also inexplicably failed to evaluate whether the father's girlfriend, Villasana, needed therapy or assistance -- even though she was serving as the children's primary caretaker. And DCFS did not consider her as a possible perpetrator when children were hurt, although she often was the only adult in the home.
Kathy Grzelak, the new chief of Kaleidoscope 4 Kids, the group that served Verna's family, keeps a laminated prayer card from the girl's funeral pinned to her office bulletin board -- a reminder of her organization's painful failures.
The wake was crowded with family, Grzelak recalled, and the girl in the tiny open casket was dressed in a glittering blue dress to resemble the fearless princess Elsa from her favorite movie, "Frozen." Grzelak said only faint traces of Verna's bruises could be seen through the mortician's makeup.
Injury after injury
The story of Verna's short life is told in confidential child welfare case files, the DCFS Inspector General's report, separate police and court records and interviews with several of her relatives.Following two separate investigations into squalor and neglect of her home -- one unfounded and the other confirmed -- Verna's parents split up, and DCFS placed the children with their father, Villasana and their new baby in 2014. In August of that year, DCFS referred the children to Kaleidoscope for intact family services. At the time, Verna was 4 years old, her brother was 6 and her sister was 9.
The state agency directed Kaleidoscope to ensure the children got proper medical care; to help their father access Medicaid, food stamps and government cash assistance; to refer him to parenting classes and other programs, and also to help the children's biological mother -- even though she had only minimal contact with the children after they left her home.
Kaleidoscope did a lot for the children. The caseworker brought them winter coats, provided a $70 gift card to buy treatments for their head lice, and tapped state funds for $1,350 when their father fell behind on his rent, records show. When Verna's older sister was not allowed to attend school because her immunizations were out of date, Kaleidoscope took her to the doctor.
But one crucial omission threatened to doom the arrangement from the start: DCFS failed to include the father's girlfriend, Villasana, in its service plan. She was the children's primary caretaker while the father worked night shifts at a local pharmacy and some days on construction sites, according to the Inspector General's report and interviews with officials and relatives. But Villasana was never put on the Kaleidoscope caseworker's radar, according to those records and interviews.
"My plan was not even constructed to serve her. There was no information leading up to Lisa being the caretaker," the former Kaleidoscope caseworker, Stephanie Lynell Ivey, told the Tribune in an interview. She subsequently left the agency and now works as a special education classroom assistant.
Suspicious injuries to the children began almost immediately, records show. That August, Verna was taken to a hospital with a broken arm -- a "spiral fracture" that often indicates abuse by twisting.
DCFS opened an abuse investigation after being notified by the hospital. But even though Villasana was the only caretaker in the home at the time, she was not investigated as a potential perpetrator. Instead, the DCFS investigation focused on the father. And because he was at work when Verna was injured, DCFS termed the abuse allegation "unfounded" and closed the case.
State officials also did not tell Kaleidoscope about the hotline call regarding Verna's broken arm. Ivey did subsequently file a note saying Verna was wearing a cast, but she accepted Villasana's explanation that Verna had fallen.
Ivey told the Tribune she was operating under the assumption that DCFS had evaluated the home where the children were placed and that it was safe.
Then, starting in October 2014, educators, relatives and medical professionals began notifying DCFS of a series of injuries to Verna's brother, along with their suspicions the children were being mistreated.
Kindergarten teacher April Palacios called the DCFS hotline that month to report that Verna's brother "came to school today with bruising all over his arm that looked like a hand print," DCFS records show. She emailed photographs of the injuries to DCFS and also reported a separate laceration on the boy's face.
Children and adults in the home gave sharply divergent accounts of how the boy was bruised, with some saying he fell while climbing a closet door frame like Spider-Man, and others that he tripped over his sister's princess slipper and hit a dresser drawer, according to DCFS and police records.
Palacios felt her concerns were never taken seriously, she told the Tribune. "It was so unfair," she said. "This was preventable."
Ivey, of Kaleidoscope, did take the boy to a doctor after Palacios reported the bruise on his arm and a cut on his face to DCFS, but the caseworker did not tell the doctor about Palacios' hotline call, and the doctor was unaware of any suspicions of abuse, records show.
Over the next several weeks, the boy's father notified Ivey several times that the boy had new head gashes or bruises after slips and falls around the house. But her checkups typically came days later, after the injuries had faded.
As she wrote in one brief report: "Upon seeing the children there were no signs of abuse or neglect. All the children appeared to be happy and healthy."
Ivey says today: "There was no sign of any physical abuse. I never observed it or witnessed it."
DCFS did open an investigation, but it was cursory -- and again targeted the father and not the main caretaker, Villasana. The DCFS investigators interviewed all three siblings, their father and Villasana in less than an hour at the family home, one case note shows.
In finding allegations of abuse against the father to be unfounded, the DCFS supervisor wrote: "Minor denied he was injured by his father. Father reported that he was at work at the time of the injury."
Because DCFS and Kaleidoscope never recognized Villasana as the primary caregiver, they never learned that Villasana felt overwhelmed by her new child care responsibilities, according to subsequent DCFS reports and interviews with her relatives.
Before Verna and her siblings arrived, Villasana had been caring only for her own newborn. Now she had three additional youngsters who were extraordinarily demanding. Two showed signs of learning and developmental disabilities, records shows, and all had been raised until then in a chaotic home with little adult supervision.
Just days before Verna's death, Villasana temporarily left the home because of the stress, according to a police report and relatives. She also had attempted suicide in recent months by taking pills and drinking bleach.
"It was just too much for one person to take care of those four kids," said Villasana's stepfather, Juan Bautista.
Checking a box
DCFS officials completely privatized the intact program in 2012 amid a deep financial crisis as well as persistent government management problems -- families were getting services for three and four years without seeing any real improvement, for example.But as the state agency's role shifted from providing direct services to overseeing and managing nonprofit contractors, DCFS simply failed at its new task, agency director Walker told the Tribune.
"When we did that privatization, we ... more or less just sent cases over and we didn't have any expectations -- or any good expectations -- about what (the nonprofits) were going to do," said Walker, who took the helm of DCFS in June as its 10th director or acting director since 2011.
DCFS does send monitors to the nonprofits' offices four times a year -- but Grzelak, of Kaleidoscope, said they only look at paperwork to make sure files are complete and rarely try to gauge the quality or impact of the agency's work.
"We can check a box and say, 'We did our three home visits.' But what did we do in that visit? What did we accomplish?" Grzelak said.
Kaleidoscope also never learns what the DCFS monitors find in those inspections, Grzelak said. "There is nothing in writing. There is no accountability. When are we going to get a more robust conversation about how we are doing?" she said. "There should be no secretiveness."
Walker said she has begun reforming the program by hiring more child protective staff and increasing DCFS's oversight and supervision of the nonprofits. "We are laser-beam focused. We're following up to make sure that our actions are leading to improvements."
She also said she is looking for additional financial resources for the intact services program. The rate paid to agencies such as Kaleidoscope has not increased for at least five years, according to providers. Last year, Gzelak said, Kaleidoscope had to supplement the $730,000 it received from DCFS with $98,000 from other sources to cover basic costs related to intact services.
Caseworkers, meanwhile, are often poorly trained, underpaid and burdened with overwhelming caseloads.
"We have young workers who are not adequately trained who are surviving and doing what is in front of them every day," Grzelak said.
The job can be "scary, heartbreaking and stressful," Ivey said.
Assigned to assist both of Verna's biological parents, Ivey was carrying 17 other cases at the time, nearly double the average of 10 recommended in the DCFS contract, according to Grzelak and Ivey.
The DCFS Inspector General determined that Ivey did not seem to understand the family or know how to counsel and assist them. Ivey disputed that.
"My role was to stabilize the family and make sure they had their basic needs met, and that's what I did. Sometimes I would visit that home twice a week. I even gave them some of my own daughter's hand-me-downs," Ivey told the Tribune. "Intact is a short-term fix, and in that short time all you're praying for as a worker is that nobody dies while this baby is on your watch."
DCFS generally expects the nonprofits to close intact services cases within six months, and the agency's contracts start to reduce payments at that point, even though Grzelak and other providers say families often still need help.
In the sixth month of Verna's case, in January 2015, Kaleidoscope closed its file. "There are no concerns regarding the safety and well-being of the children," a Kaleidoscope supervisor wrote.
Four months later, Verna was found in the bathtub dead.
Palacios, the teacher, said she was shattered by the news. "I started crying," Palacios recalled. "What I feared most could happen, happened. I was very angry at DCFS because they had an investigation going on. They had visited the family."
Only after Verna's death did DCFS investigators conduct forensic interviews with her siblings -- taking them outside the home to question them separately about mistreatment, instead of interviewing them for a few minutes at home with their parents nearby.
In these sessions, the children readily described being whipped, kicked and abused by Villasana and other adults, records show.
On the way to one interview, Verna's brother asked a DCFS investigator if Verna was ever coming back, according to confidential DCFS case notes. The investigator told the boy that Verna "is in his heart and all he had to do is think about her and close his eyes and he would see her."
Verna's older brother and sister now live with a foster family out of state.
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