When paramedics arrived at his Palmdale home last week, 8-year-old Gabriel Fernandez's skull was cracked, three ribs were broken and his skin was bruised and burned. He had BB pellets embedded in his lung and groin. Two teeth were knocked out of his mouth.
His mother's boyfriend allegedly told authorities that he beat Gabriel repeatedly for lying and "being dirty," according to confidential county documents reviewed by The Times.
Los Angeles County's Department of Children and Family Services left Gabriel in the home despite six investigations into abuse allegations involving the mother over the last decade.
He died Friday of his injuries. His mother and her boyfriend were charged with murder and torture. They have not entered pleas, but records show Gabriel's mother told paramedics that the boy's injuries were a result of self-mutilation.
Social workers appeared to miss numerous warning signs at the home, according to the county documents.
Gabriel had previously written a note saying he was contemplating suicide, records show. His teacher told authorities he often appeared bruised and battered at school. BB pellets left bruises across his face. For reasons that are not clear, all but one investigation was determined to be "unfounded."
At the time of Gabriel's death, there was yet another, unresolved allegation of child abuse in his file. That referral has lingered two months past a legally mandated deadline for completing an investigation, records show.
The social worker assigned to that case did not make first contact with the family until 20 days after the complaint was received, and then "made minimal attempts to investigate," according to an internal county report.
"The red flags were all over the place. They were ignored. It is just inexplicable to me," said county Supervisor Zev Yaroslavsky, noting that the Sheriff's Department was also aware of the abuse allegations.
Department of Children and Family Services Director Philip Browning acknowledged in an interview that the system failed Gabriel.
The case illustrates a need for more "critical thinking and common sense" in evaluating cases, he said.
Four social workers have been placed on desk duty pending possible disciplinary action.
But Gabriel's death sent fresh shock waves through the county's child protection bureaucracy, still struggling to implement reforms after dozens of abuse and neglect deaths in recent years involving children who had been under the system's supervision.
The department has been criticized for lenient treatment of workers who fail to properly protect children in cases such as Gabriel's. One recent internal agency review found no workers had been fired in 15 instances where children died, even when their errors were deemed "egregious."
"I feel like they all should be fired," said Elizabeth Carranza, Gabriel's aunt. "They didn't listen to my nephew. They were completely deaf and blind."
Gabriel's relatives and friends have mobilized to put pressure on the department to hold workers accountable and take evidence of child abuse more seriously. Several protests have been staged, and a Facebook page has gathered over 20,000 supporters.
"We are protesting their handling of this case 300% because we want to make sure this never happens again," Carranza said.
Browning said Gabriel's case is complex and defies "simple solutions," but he encouraged people who know about child abuse to contact department managers if they encounter non-responsive workers.
"If all else fails," he said, "I want them to contact me. I answer calls from foster children, staff, foster parents, anyone."
A decade ago, Gabriel's mother, Pearl Fernandez, came to the attention of county social workers when her oldest son suffered a head injury during a car accident. He was wearing no seat belt, prompting an allegation of severe neglect, according to county records.
A year later, a relative reported that Pearl beat the same son and did not want him, but social workers decided the complaint was unfounded.
Gabriel was born in 2005 and went to live with relatives soon thereafter. He had little interaction with his mother for years, relatives said, and the two barely acknowledged each other at family gatherings.
Pearl later told social workers that she had a history of gang involvement, drug use and mental health problems.
In 2007, social workers received a complaint that Pearl did not feed one of her daughters and threatened to break her jaw when she cried.
The following year, Pearl was convicted of using a weapon in a reckless manner in Texas and was sentenced to two weeks behind bars, according to court records.
In October, relatives said Pearl suddenly reclaimed Gabriel and two siblings from her parents. Emily Carranza, Gabriel's cousin, alleged "it was for the welfare money." Pearl told social workers she was concerned about the treatment of her son by relatives.
Within days, a call came to the child abuse hotline alleging that she was physically abusing the children. Social workers substantiated neglect but allowed her to keep her children and enter counseling.
Another call in October from Gabriel's teacher said he was bruised on his face and hands and the boy reported he was hit with a belt buckle that caused bleeding.
The following month, the teacher said he had scratches and a "busted lip," which the boy attributed to being punched by his mother, records show.
In January, the teacher said his face was swollen and he had bruised dots all over his face. She said Gabriel told her his mother shot him in the face with a BB gun, according to county records.
At one point, his mother sent Gabriel to school in girl's clothing to humiliate him, relatives said.
During the investigations, Gabriel often recanted his stories of abuse. An internal county review criticized social workers for failing to interview Gabriel in a neutral setting away from his mother.
In March, Gabriel's therapist called 911 after discovering a suicide note by Gabriel. Authorities dismissed the complaint without removing him or hospitalizing him because he had no specific plan to carry out a suicide, records show.
The same month, Gabriel's mother ended contact with county social workers, saying she did not need their help.
A new complaint was submitted by Gabriel's therapist on March 26 saying the boy reported once being forced to perform oral sex on an older relative, according to county records.
Gabriel later withdrew the allegation when interviewed by a social worker at his home. The investigation of the complaint remains open.
On May 22, firefighters were summoned when Gabriel stopped breathing. Two days later, he died. His siblings told investigators they heard "something" happen to Gabriel, but declined to elaborate, according to the county reports.
The county has been battling a backlog of child abuse investigations for years. The problem has been especially acute in the Antelope Valley, where Gabriel lived, because some of the department's least experienced social workers work there with the highest caseloads.
Only South Los Angeles and Compton receive lower levels of service, according to a 2010 report.
Although significant progress has been made in reducing the backlog, 3,450 children are currently subject to overdue investigations. County officials noted that 37 of California's 58 counties have a poorer record of meeting mandated investigation deadlines.
Times researcher Kent Coloma contributed to this report.