How the child welfare system failed Noah Cuatro

Noah Cuatro makes a face at the camera
Noah Cuatro in an undated photo.
(Grand jury evidence)

Good morning, and welcome to the Essential California newsletter. It’s Friday, Aug. 20. I’m Jaclyn Cosgrove.

In a damning investigation of the L.A. County child welfare system, my Times colleague Matt Hamilton worked with Garrett Therolf and Daniel Lempres at the Investigative Reporting Program at UC Berkeley to explore the case details in the killing of 4-year-old Noah Cuatro.

Noah’s family had a long history with the Los Angeles County Department of Children and Family Services. The Times-UC Berkeley investigation found “that errors, misjudgments and bureaucratic conflict within the child welfare system — including among top supervisors — blocked multiple opportunities to protect Noah.”

Before I discuss those details, I wanted to first talk about Noah and how the people who love him remember him.


In interviews, Noah’s great-grandmother Eva Hernandez described him as a “beautiful little guy.” His time living with her appears to have been his happiest; he spent enough time with Hernandez that Noah sometimes called her “Mommy.” She remembered during one doctor’s visit when Noah persuaded those in the waiting room to sing “Old McDonald” with him.

“Every day, he’d tell me, ‘Grandma, you know what time it is? It’s time for you to hold me and tell me you love me,’” she said.

At one point in his short life, Noah told a DCFS staffer he did not want to leave Hernandez and his grandfather: “This is my home. Grandma and Grandpa love me.”

Noah died July 6, 2019, a month shy of his fifth birthday.

This Times-UC Berkeley investigation marks the first time that the public can read a full account of the choices that county workers made in this family’s case.

Noah Cuatro with the book "Noah's Ark"
An undated photo of Noah Cuatro.
(Grand jury evidence

One of the most jarring choices was not carrying out a court order to remove Noah from his parents’ custody and have him undergo a medical or sexual abuse exam.


As the Times-UC Berkeley investigation explains, once the removal order was made by the judge: “DCFS had 10 days to get Noah out and seen by a doctor, even if it required barging into the home with police. Carrying out that removal order could have saved Noah’s life.”

Instead, DCFS ignored the order and kept Noah with his parents. He died less than two months later. His parents, Ursula Juarez and Jose Cuatro, are accused of torturing and murdering him.

Some officials argue that DCFS couldn’t have foreseen Noah’s death.

“You went from virtually no physical abuse to the worst kind possible: The child was murdered,” said Michael Nash, who facilitates child protection oversight for the Los Angeles County Board of Supervisors.

But as this investigation shows, DCFS workers not only ignored the removal order and didn’t follow a court order for Noah to receive a medical exam, but also didn’t sound the alarm when his parents repeatedly failed to comply with the terms of their custody, including attending therapy. And, in the midst of the investigation into whether Noah was being abused, workers let Noah’s mother go home with her newborn child — even after a hospital social worker expressed concerns, and the mother’s psychiatric exam showed she had “traits of a sociopath.”

DCFS Director Bobby Cagle refused to tell the Times-UC Berkeley team whether any of the workers in Noah’s case were disciplined. Instead, he stood by his agency’s policies.

“It’s very difficult for, I think, the public especially to understand why those decisions were made, but I’m confident that the decisions that were made were the right ones,” he said.

You can read an edited transcript of the interview that the Times-UC Berkeley team had with Cagle here.

Noah’s parents — Ursula Juarez and Jose Cuatro — were indicted on murder and torture charges and have each pleaded not guilty. Their attorneys declined to comment.

As you read this story, you might think of two other boys who died while under DCFS supervision: 10-year-old Anthony Avalos, who died in 2018, and 8-year-old Gabriel Fernandez, who died in 2013. Avalos’ mother and her boyfriend are accused of torturing him days before his death, and Fernandez’s mother and her boyfriend were convicted of his torture-murder. All three boys lived in the Antelope Valley.

This is not an easy read, especially as we all continue to face the daily stress and uncertainty from the COVID-19 pandemic. But we as a society must continue to pay close attention to system failures, especially those that involve the safety of our most vulnerable children.

And now, here’s what’s happening across California.

Note: Some of the sites we link to may limit the number of stories you can access without subscribing.

A truck burns in brush fire.
A truck and home burn as the Dixie fire tears through the Indian Falls neighborhood of unincorporated Plumas County. The fire started only a few miles from the origin of the deadly Camp fire.
(AFP/Getty Images)

Wildfires, yet again, prompt air quality advisories in Northern California. Smoke from a dozen major wildfires is spreading across Northern California, darkening skies, dropping ash and creating health hazards from Lake Tahoe to San Francisco. Officials have issued air quality alerts warning of hazardous conditions that could last into the weekend. Robin McBain, a San Francisco resident who awakened to yet another day of smoke and soot, asked the question on everyone’s mind: “How much more of this can the environment withstand, and how much more of this can we take?” Los Angeles Times

Why the Delta variant means that masks, and mandates for vaccines and testing, may persist. The rise of the Delta variant has upended previous optimistic projections of herd immunity and a return to normal life, with many health experts believing mask mandates and tougher vaccine requirements will be needed in the coming months to avoid more serious coronavirus surges. Los Angeles Times

L.A. County COVID-19 deaths top 25,000 as the Delta variant continues to spread. Los Angeles County reported 35 additional COVID-19 deaths Thursday, pushing the region past 25,000 total fatalities over the course of the pandemic. While some health officials and experts have expressed optimism that the latest wave may not lead to the same sort of harrowing counts seen over the fall and winter, the new numbers are further evidence that some of those infected with the coronavirus will pay the pandemic’s ultimate price. Los Angeles Times


L.A. had a golden opportunity to house homeless people in hotels — but fell short of its goal. Thousands of empty hotel rooms, unusable because of COVID-19 restrictions on discretionary travel, were originally seen by local and state leaders as an opportunity to help people experiencing homelessness. But though the program, now winding down, improved the lives of many, it never got close to its goal. Los Angeles Times (This story is exclusive to Times subscribers.)

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Recall candidate Larry Elder once said it’s “smart” for women to tolerate crude workplace behavior by men. Conservative radio host Larry Elder, the Republican front-runner to replace Gov. Gavin Newsom if he is defeated in the Sept. 14 recall election, once said women should tolerate some crude language and behavior from men in the workplace and that sexual harassment doesn’t hold women back in their careers. San Francisco Chronicle


The remote hiking area where a Northern California family was found dead is treated as a hazmat site. Authorities remained mystified over how a family of three, along with their dog, perished on a remote hiking trail in Mariposa County. “This is a very unusual, unique situation,” said Kristie Mitchell, a spokesperson for the Mariposa County Sheriff’s Office. “There were no signs of trauma, no obvious cause of death. There was no suicide note. They were out in the middle of a national forest on a day hike.” San Francisco Chronicle

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A million acres burned already as California enters peak fire season. Photojournalists from The Times and other outlets have traveled across California to document how fires have leveled small mountain towns and left landscapes charred. Have a look at their work. Los Angeles Times

A small totem pole near the roadside as traffic streams by
Motor traffic streams along California Highway 50 near the community of Kyburz, which was under mandatory evacuation orders because of the nearby Caldor fire.
(Luis Sinco / Los Angeles Times)

Where the water runs dry. Thousands of households across the San Joaquin Valley have wells that have gone dry amid increasingly hot temperatures and drought. These issues have plagued rural towns and unincorporated areas here for decades. But in the era of the coronavirus, these inequities have become magnified in an area that already had some of the highest poverty rates in the state. Los Angeles Times

“They just can’t stop these fires.” An unprecedented wildfire southwest of Lake Tahoe known as the Caldor fire has exploded dramatically, forcing thousands to flee their homes in late-night evacuations and prompting the emergency closure of a national forest as firefighters struggle to catch up with the blaze’s overwhelming spread. The Mercury News


A good place to see creative face masks. A dominatrix convention is whipping its way through town this week, offering everything you need for your home dungeon and more. Whether you aspire to be a tie-er-upper or the tie-er-uppee, DomCon—the “world’s premier professional and lifestyle domination convention” — is coming to the airport Hilton this week to turn fantasies into realities. Los Angeles Magazine

A swell day at the beach. Surfers flocked to the Wedge in Newport Beach on Thursday to take advantage of the biggest swell of the summer. Enjoy these photos of people having fun, a reminder there’s still good things in this world. Orange County Register

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Los Angeles: 79. San Diego: 75. San Francisco: 66. San Jose: 81. Fresno: 97. Sacramento: 90.

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