Court Opinion

ID: 4655633
Source: CourtListenerOpinion
Date Created: 2021-01-29 01:02:16.910593+00
Date Added: 2024-06-11T08:00:24.803367
License: Public Domain

Filed 1/28/21 In re D.V. CA2/1
   NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions
not certified for publication or ordered published, except as specified by rule 8.1115(b). This opinion
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IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                         SECOND APPELLATE DISTRICT

                                        DIVISION ONE

 In re D.V.,                                                      B307336

 a Person Coming Under the                                         (Los Angeles County
 Juvenile Court Law.                                               Super. Ct. No. 20CCJP01420)

 LOS ANGELES COUNTY
 DEPARTMENT OF CHILDREN
 AND FAMILY SERVICES,

           Plaintiff and Respondent,

           v.

 LEONCIO V., et al.,

           Defendants and Appellants.

      APPEALS from an order of the Superior Court of Los
Angeles County, Michael E. Whitaker, Judge. Affirmed.
      Gina Zaragoza, under appointment by the Court of Appeal,
for Defendant and Appellant Leoncio V.
     Annie Greenleaf, under appointment by the Court of
Appeal, for Defendant and Appellant Julianna R.
     Rodrigo A. Castro-Silva, Acting County Counsel, Kim
Nemoy, Assistant County Counsel, and Veronica Randazzo,
Deputy County Counsel, for Plaintiff and Respondent.
                    _____________________
      Father Leoncio V. and mother Juliana R. appeal from the
juvenile court’s July 8, 2020, dispositional order.1 Father and
Mother maintain that the juvenile court erred in removing their
son, D.V., from them because the Department of Child and
Family Services (DCFS) failed to make reasonable efforts to
prevent removal. They contend that insufficient evidence
supported the juvenile court’s finding pursuant to Welfare and
Institutions Code section 361, subdivision (c)(1),2 that no
reasonable means existed to protect D.V. without removing him
from parental custody.
      At the time of his birth, D.V. was diagnosed with severe
medical conditions that required a high degree of care. Due to
D.V.’s complex medical needs and the demonstrated inability of
the parents to provide the required level of care, we conclude the
juvenile court did not err in removing D.V. from his parents, and
affirm the juvenile court’s dispositional order.

      1 Neither parent challenges the juvenile court’s
jurisdictional findings.
      2All subsequent statutory references are to the Welfare
and Institutions Code unless otherwise specified.

                                 2
      FACTUAL AND PROCEDURAL BACKGROUND
A.    Mother’s Prior History with DCFS
      Mother has three prior, substantiated child welfare
referrals. First, on January 30, 2014, the juvenile court
sustained a petition relating to Mother’s three older children,
J.D, G.D., and O.D., due to domestic violence between Mother
and her former husband and the children’s father, M.D., and due
to M.D.’s alcohol use. The juvenile court terminated jurisdiction
in July 2014, with Mother and M.D. sharing custody of the
children.
      In May 2017, DCFS received a referral alleging that
Mother’s fourth child, F.D., a toddler, was a victim of general
neglect and that his siblings were at risk. According to the
referral, F.D. was found wandering alone on a major street. He
was wearing a shirt but no underwear. Mother had been asleep
in the apartment. DCFS visited the home, observed F.D. could
open the front door, identified areas in the home where F.D.
could get out, and advised Mother to take corrective action.
DCFS determined F.D. was safe and did not take further action.
      In June 2017, DCFS received a referral that alleged the
children were victims of general neglect following another
instance of F.D. wandering away from the family’s second story
apartment to a supermarket parking lot. Mother blamed F.D. for
the incident. In September 2017, the juvenile court found the
children to be described by section 300, subdivisions (b) and (j),
due to Mother’s failure to provide adequate parental supervision.
The court ordered Mother to participate in a parent education
program, individual counseling, a mental health evaluation, and

                                3
Regional Center services.3 Although Mother partially complied
with the classes and counseling, she did not participate in
Regional Center services. In March 2018, the juvenile court
awarded sole legal and physical custody of the four children to
M.D. and permitted Mother to have monitored visits. The
juvenile court noted that Mother’s visits were monitored because
she had not made substantial progress in the Regional Center
services.
B.    D.V. Is Born and Requires Medical Care
      D.V. was born in July 2019, at 29 weeks gestation. D.V.
has multiple medical problems, including global developmental
delays; a seizure disorder; chronic lung disease and sleep apnea;
and a feeding intolerance. He requires oxygen treatment and
feeding through a gastrostomy tube (G-tube). Due to his medical
needs, D.V. remained in the hospital. In September 2019, he was
transferred to the neonatal intensive care unit (NICU) at
Children’s Hospital Los Angeles (CHLA). D.V. remained at
CHLA through March 10, 2020.
      Between September 2019 and January 2020, Mother and
Father met with hospital staff on four occasions to receive
information to prepare them for D.V.’s discharge. On
September 13, 2019, Father and Mother had their first meeting
at the NICU to discuss D.V.’s medical needs and the

     3  Regional Centers are nonprofit corporations that contract
with the California Department of Developmental Services to
provide services and resources to individuals with developmental
disabilities. (See L.A. County Dept. of Mental Health, Regional
Centers for the Developmentally Disabled
https://dmh.lacounty.gov/our-services/developmental-
disabilities/regional-centers/ [as of Jan. 28, 2021].)

                                4
requirements for D.V. to be discharged to their care. On
November 1, 2019, a second meeting covered D.V.’s medical
treatment to date, and the next steps and expectations. During a
third meeting on January 9, 2020, the parents were provided
information about the G-tube; however, the parents expressed
hope that D.V. would not need a G-tube upon his discharge. The
fourth meeting on January 27, 2020, focused on understanding
the G-tube and its basic care. During this fourth meeting, the
parents requested that they be provided further G-tube training,
which the hospital provided to them on February 16, 2020.
C.    DCFS’s Investigation Relating to D.V.
      1.     Evidence of the Parents’ Initial Resistance to
             Recommended Medical Care
      On January 20, 2020, DCFS received a referral alleging
that D.V. was a victim of general neglect. According to the
referral, earlier that day, Mother and Father were observed to be
intoxicated at the hospital in D.V.’s presence and were asked to
leave. The referring party also stated the parents lacked an
understanding of how to properly care for D.V., and they had
attempted to feed D.V. orally that day, causing him to cough.
      On January 21, 2020, a DCFS social worker interviewed
the hospital social worker (HSW), hospital nurse, an occupational
therapist feeding specialist, Mother, and Father. The HSW
expressed concern about the parents’ drinking and lack of
understanding about D.V.’s medical needs, including his need for
a G-tube. Although the parents seem to comprehend in the
moment what was told to them, soon after, the parents asked the
same questions. The parents made statements such as, “Don’t
feed the baby overnight and you’ll see he will be able to feed on
his own.” Further, the parents stated they believed the doctor

                                5
was lying about D.V.’s need to be fed through a tube and overall
medical diagnosis.
      The hospital nurse told the DCFS social worker that D.V.
was currently fed via a nasogastric tube, and was only fed by an
occupational therapist feeding specialist. The nurse stated that
the parents were very concerned and attentive, but lacked an
understanding of how to care for D.V. The nurse also stated that
on January 20, 2020, the parents were arguing, and Father
confirmed that he had consumed alcohol. Mother did not appear
intoxicated.
      The occupational therapist feeding specialist reported that
D.V. struggled to feed on his own. When bottle fed, he coughed
and appeared to be in respiratory distress. She stated that D.V.
was at high risk of aspiration pneumonia, his back posture was a
“C shape,” and his eyesight was “unknown.” She also reported
concern that the parents did not comprehend the severity of
D.V.’s needs. She noted they continually asked to bottle feed
him.
      A DCFS social worker interviewed Father. Father was
frustrated that the medical staff would not permit him to bottle
feed D.V. Father requested that they try bottle feeding for seven
days, and if D.V. could not bottle feed, Father would approve the
G-tube procedure. The hospital staff granted the parents four
days to bottle feed D.V., but after he coughed during one of the
feedings, the feeding specialist suspended the parents’ ability to
bottle feed him. Father told the social worker that if D.V. was
not fed overnight, he would be able to latch on and feed on his
own. Father denied feeding D.V. by bottle against doctor’s
recommendations.

                                6
       Father also reported that doctors had advised him that
D.V. was not able to move, his brain was “not well,” and that they
were unsure of his eyesight. Father did not believe these things
to be true because he observed D.V. moving and smiling, and
believed D.V. could see. Father acknowledged that D.V. took
medicine to keep his seizures under control.
       Father was remorseful about drinking three beers at a
restaurant and then visiting the hospital. He loves D.V. and
denied handling him in an unsafe manner. As to whether he was
arguing at the hospital with Mother, Father explained he and
Mother speak loudly and that he uses curse words “a lot.”
       DCFS interviewed Mother at home. She reported she had
been in a relationship with Father for six years. She confirmed
she had a prior history with DCFS and had not had contact with
her other four children for more than a year. Mother expressed
frustration with the hospital staff for not feeding D.V. enough
food and for the bottle-feeding restrictions. She stated D.V. was
healthy and could be bottle fed without any medical risks. She
denied bottle feeding him against doctor’s recommendations. She
also stated that D.V.’s oxygen levels were at 98 and he is
receiving more oxygen than he needs. She acknowledged D.V.
has seizures that are under control with medication. She stated
she visits D.V. nearly every evening, and bathes and cares for
him.
       Concerning Father’s intoxication at the hospital, she
explained they had walked from the hospital to a local
restaurant, and Father consumed three beers with his food. She
denied the couple argued, stating they may have spoken in a loud
tone of voice.

                                7
      A DCFS public health nurse (PHN) reviewed D.V.’s medical
records and spoke with the CHLA nurse. As of January 22, 2020,
the parents refused the G-tube placement procedure for D.V.’s
feeding.
      On January 28, 2020, the HSW contacted DCFS. She
reported she was concerned about both parents’ careless
behavior. She stated that on January 26, 2020, D.V.’s
nasogastric tube had been unlashed during a feeding, and when
the nurse tried to fix it, Father laughed and stood in front of the
nurse, obstructing the nurse. Father denied purposely
obstructing the nurse’s ability to access D.V. The HSW also was
concerned because Mother advised that D.V.’s nasal cannula for
oxygen therapy had dislodged from his nasal passage for two and
a half hours. However, Mother did not report this or put the
cannula back in.
      2.    Additional Efforts to Train the Parents Concerning
            D.V.’s Medical Needs
      On January 30, 2020, Mother advised DCFS she was more
comfortable in learning about the G-tube. As to the oxygen tube
becoming detached, Mother stated that she now understood from
the doctor that D.V. needed the oxygen treatment.
      On January 30, 2020, the PHN confirmed the parents
agreed to the G-tube placement for D.V. D.V. underwent the G-
tube procedure on February 11, 2020.
      On February 12, 2020, a nurse discussed the G-tube and
D.V.’s medications with Mother and Father for 30 minutes. The
nurse showed the parents how to disconnect the feeding tube and
had them practice administering medication. The following day,
a nurse assisted Mother and Father in providing medications to
D.V.

                                8
      On February 16, 2020, the parents attended a G-tube
training session.4 Among other things, the training included
what to do if the tube fell out, how to clean the tube, and how to
administer food and medication through the tube.
      The hospital also required the parents to participate in an
in-hospital, hands-on 24-hour care period during which the
parents would have one-on-one training with a nurse monitoring
D.V.’s medical needs, feeding, and G-tube cleaning. During this
session, the parents would be prompted “to do everything without
assistance but if done incorrectly they will be retrained until it’s
done correctly.” The parents would then each need to complete
an additional 12-hour hands-on training during which each
parent would independently care for D.V., with a nurse
supervising during certain tasks such as feedings and medication
administration.
      On February 18, 2020, the social worker was advised the
parents had successfully completed the 24-hour training,
although they still needed to complete nebulizer training.5 The
HSW stated that Mother did well on flushing the tubes but had
to be reminded to wash her hands before handling the tubes. The
HSW reported that Mother understood D.V.’s medical needs and
had the “best intentions to care for the child.” However, the

      4 Although this training was scheduled for February 14,
2020, the medical records suggest it occurred on February 16,
2020.
      5 Whether the parents successfully completed the training
was called into question by a subsequent review of the training
report by a medical doctor, which noted the parents “were unable
to perform the entire training.”

                                 9
bedside nurse observed that the parents appeared to need more
practice.
       During the 24-hour training, Father insisted D.V. was
“normal,” and did not need oxygen treatment or a nebulizer.
When a nurse told him that D.V. had chronic lung disease,
Father responded, “no, he does not.” The next day, Father
appeared agitated and challenged the nurse when she advised
him that he needed to participate in nebulizer training.
       On February 20, 2020, the HSW reported to DCFS that the
medical team had significant concerns that D.V.’s parents did not
understand his medical needs. The parents did not believe D.V.
had a lung disease, required oxygen treatment, or required all his
medications. Thus, the HSW feared if D.V. was released to his
parents, that they would not provide the necessary medical care.
Further, although Father had been trained to give D.V. 0.5 liters
of oxygen, staff observed him “turn[ing] it up to” eight liters. The
HSW also reported she had made provisions for an eight-hour, in-
home nurse for five to seven days a week. Still, the HSW
expressed concern that Father did not seem to be interested in
learning about D.V.’s care because, as he explained, he would
often be away at work. She stressed that it was important that
Father learn about D.V.’s tube feeding, oxygen requirements, and
medication administration because he was the backup caregiver
when Mother was sick or could not perform these tasks. The
DCFS social worker therefore spoke with Father and advised him
of the importance of being able to perform these tasks. Father
agreed to participate in future trainings.
       On February 20, 2020, a CHLA doctor wrote a letter to the
PHN in which the doctor opined it would be unsafe to release
D.V. to his parents. The doctor explained that D.V. was an

                                10
“incredibly medically complex six-month old.” The doctor
warned, among other things, that, “[i]f he were to miss [his]
breathing treatments, he would have worsening of his lung
disease, which could potentially cause permanent neurologic
deficits, brain damage, and possible death.”
       According to the doctor, the medical team believed neither
parent understood the severity of D.V.’s medical diagnoses, and
that each parent had limited medical literacy or medical
competency. Based on the medical team’s experiences, the doctor
believed it was likely the parents would stop giving D.V. some
medications, take him off his oxygen, or forget how to give him G-
tube feedings, which would put D.V.’s life in danger.
       The doctor also noted concern that Mother did not know
how to use public transportation, which could impede her ability
to get D.V. to medical appointments.
       On February 22, 2020, Father asked to speak with a doctor
so that he could tell the doctor that D.V. was “on so many
medications, he doesn’t need all of these medications. I have
never seen an attack [seizures], his mom has never seen an
attack and you guys haven’t seen an attack.” After the nurse
explained that the medications prevent the seizures, Father told
the nurse that he wanted the doctors to stop the medication so
that he could observe D.V. have a seizure. The nurse advised
Father that would not be appropriate or benefit D.V. in any way.
Father insisted D.V. was “not sick,” and demanded the doctors
show him proof that D.V. needed the medications. Mother
interjected, explaining that the nurse knew more about D.V.’s
medical needs than Father.
       A nurse also reported that during a visit, Mother held D.V.
in a manner that caused pulling on his G-tube. Mother had

                               11
difficulty removing D.V.’s gown, covering his face with the gown
and not using proper head support. Additionally, after Mother
administered medication, D.V. began to gag and neither parent
reacted, even though Mother had received training on
January 25, 2020, to reposition D.V. to avoid choking. Staff also
noticed that on one occasion when Father held D.V., Father
began to rapidly rock him. The nurse told Father that this
activity could make D.V. throw up or become injured. Father
responded that D.V. liked it and that it was rough play. Father
stopped after Mother intervened and told him to stop.
       3.    The Parents’ Participation in the 12-hour Independent
             Care Training
       On February 23, 2020, Mother attended a 12-hour hands-
on training session during which she would independently
perform the tasks necessary for D.V.’s care. The supervising
nurse corrected Mother in several tasks. For example, with
respect to flushing D.V.’s G-tube, Mother failed to realize she had
drawn 3 units of air into the flushing syringe instead of water,
which would cause D.V. to get air in his stomach. Further,
Mother did not close and disconnect the necessary tubes or press
the correct buttons on the G-tube pump. Mother confirmed to the
nurse that D.V.’s next feeding would be in two hours. However,
Mother did not contact the nurse at the time of feeding to bring in
the food, and the nurse found Mother asleep in D.V.’s room.
Approximately six hours later, Mother needed prompting to
remember D.V.’s medications were due. Following
administration of medications, Mother reconnected the feeding
tube, pressed “run,” but forgot to re-open the feeding tube so that
the medication could travel through to D.V. Then, a couple hours
later, Mother attached a feeding bag and attempted to feed D.V.

                                12
She needed reminding that “the bag had run dry and the tubing
had air in it so she needed to prime it again.” When the pump
again beeped, the nurse pointed out that the tubing had a kink.
After Mother left the hospital, a respiratory therapist informed
the nurse that D.V. was connected to an empty tank and not to
the wall oxygen. Mother did not pass the 12-hour independent
care period. Staff noted that if the mistakes had not been noticed
by bedside nursing staff, D.V. would have missed medications
and feedings, and would have been without his supplemental
oxygen for extended periods of time.
       Concerns were also noted regarding Father’s 12-hour
training that occurred on February 24, 2020. Father needed to be
cued as to the steps for stopping feeds. He had difficulty
administering medications, he did not understand the
measurements, and he did not know the purpose of each
medication. He needed to be reminded not to leave an adaptor
near D.V. because he might put it in his mouth. Father did not
pass the 12-hour independent care training because he was
unable to administer all the medications independently, was late
on some medications, and required instruction to clamp the G-
tube after medication administration.
       4.    The Hospital Discharge Plan
       On February 24, 2020, the hospital reported that D.V. was
stable and ready to be discharged. On or about February 26,
2020, the PHN reviewed D.V.’s medical files and concluded that
D.V. would require “[c]ontinuous G-tube feeding [and]
[c]ontinuous oxygen.” Accordingly, the PHN recommended that
D.V.’s caregiver be certified to address these medical needs.
       On March 5, 2020, the social worker informed the parents
that the hospital was unwilling to release D.V. to their care.

                               13
Father expressed that he did not understand the hospital’s
concern because he believed he had passed the trainings.
Further, Father did not think an in-home nurse was necessary
because he and Mother knew how to take care of D.V. Mother
also stated she was told that she passed the training.
       That same day, DCFS filed an application to remove D.V.
from the parents. The juvenile court authorized removal.
D.     DCFS Files a Section 300 Petition Concerning D.V.
       On March 10, 2020, DCFS filed a petition alleging that
D.V. came within the juvenile court’s jurisdiction pursuant to
section 300, subdivision (b)(1). In count b-1, DCFS detailed
D.V.’s multiple medical problems, which included epilepsy and
chronic lung disease of prematurity. The allegations referenced
D.V.’s need to receive oxygen treatment around the clock, his
feeding intolerance, necrotizing enter[o]colitis, and the insertion
of a gastrostomy feeding tube. The petition alleged that Mother
and Father have a limited ability to provide “appropriate medical
care and supervision.” They did not believe “the child has chronic
lung disease and breathing problems and disagree with the
doctor’s treatments.” They “failed to show medical competency
due to [a] lack of comprehension of the child’s severe medical
needs.” Mother insisted D.V. was healthy and believed he could
be bottle fed with no medical risks. She resisted the G-tube
procedure as unnecessary. The parents failed to pass the 12-hour
independent care training. The petition summarized, “Said
inability to provide appropriate medical care and supervision of
the child by the parents endangers the child’s physical health and
safety and places the child at risk of serious physical harm and
damage.”

                                14
      In count b-2, DCFS alleged that Father abused alcohol,
rendering him incapable of providing regular care to D.V. The
juvenile court ultimately dismissed count b-2.
      On March 10, 2020, CHLA discharged D.V., and DCFS
placed him with a foster parent.
E.    The Juvenile Court Orders D.V. Detained from
      Parents
      At the March 11, 2020, detention hearing, the juvenile
court ordered D.V. detained from the parents. The court ordered
DCFS to assist the parents “regarding any/all medical training
required for the care of minor.” The court explained, “[t]hat will
include the 12-hour course that’s referenced in the detention
report and all other courses that the department may determine
may be necessary.” Additionally, the juvenile court ordered that
DCFS provide services and referrals for the parents, including
counseling, parenting programs, and psychological/psychiatric
evaluations and treatment. Mother and Father were to have
monitored visitation with D.V. twice per week.
      The juvenile court scheduled the jurisdictional and
dispositional hearings for May 11, 2020. However, due to delays
associated with the Covid-19 pandemic, these hearings were
continued to July 8, 2020.
F.    Events Occurring Between the Detention Hearing
      and the Jurisdictional and Dispositional Hearing
      On March 19, 2020, due to the state of emergency created
by the Covid-19 pandemic, Governor Gavin Newsom issued
Executive Order N-33-20, by which he ordered Californians to
“stay home . . . except as needed to maintain continuity of
operations of the federal critical infrastructure.” Under the
order, “[t]he healthcare delivery system shall prioritize services

                                15
to serving those who are the sickest . . . .” (Governor’s Exec.
Order No. N-33-20 (Mar. 19, 2020).)6
      In its May 11, 2020, jurisdictional and dispositional report,
DCFS recognized that “[i]n March 2020, the President of the
United States, the Governor of the State of California and the
Mayor of Los Angeles declared a State of Emergency due to the
current Covid-19 pandemic, and issued [s]ocial [d]istancing
mandates. Due to the directives issued by the Federal, State and
Local Governments for [m]aximum [s]ocial [d]istancing, [DCFS]
has implemented temporary changes for specific policies in order
to abide by the said guidelines and ensure the safety of staff and
the community while completing the essential social work
functions.” Maximum social distancing practices include
“telephonic/virtual contact and interviews between staff and
clients.” Thus, due to the pandemic and D.V.’s compromised
health, Mother and Father’s visits with D.V. were limited to two
video conferences per week.
      On April 16, 2020, a social worker interviewed Mother and
Father. Mother reported she did not understand why DCFS said
she was not capable of caring for D.V. She said she took the
necessary training and was told she had passed. She claimed the
hospital lied to her. Mother questioned the hospital staff’s efforts
to bottle feed D.V., and wanted “to see with [her] own eyes that
he wasn’t able to.” She understood D.V. has medical needs, but
stated that she is his mother and she believes she is able to care

      6See https://www.gov.ca.gov/wp-
content/uploads/2020/03/3.19.20-attested-EO-N-33-20-COVID-19-
HEALTH-ORDER.pdf [as of Jan. 28, 2021].

                                 16
for him. Mother reported she was on the waiting list for Regional
Center services.
       During Father’s interview he stated, “The hospital lied to
us a lot. He doesn’t need oxygen right now. The person who was
giving him oxygen treatment in the hospital told me he didn’t so I
don’t understand why he needs it now. The problem here is that
I question the doctor and their treatment plan for my son and
because I do[,] the hospital thinks I’m the problem. . . . I
personally saw that [D.V.] was able to drink [one ounce] on his
own. Just because he started coughing[,] they stopped. I think
it’s normal for a baby to cough[,] don’t you?”
       A Regional Center employee reported to DCFS that the last
time Mother reached out to them was on March 21, 2018. The
employee reported that Mother had poor follow-through and
expressed some measure of denial about her needs. A DCFS
social worker who worked with Mother in 2018 also reported that
Mother did not comply with the court’s orders and did not follow
up with the Regional Center.
       Mother began individual therapy on April 15, 2020, and
had attended eight sessions of parenting education as of June 25,
2020. Father began individual counseling and had participated
in four counseling sessions. Father attended 10 parenting
classes, during which he was observed to be very committed.
       On April 24, 2020, the health officer for the Los Angeles
County Department of Public Health issued an order limiting
public access to health care facilities and mandating procedures
to slow the transmission of Covid-19.7

      7 See County of Los Angeles Department of Public Health,
Order of the Health Officer for Control of Covid-19 (Apr. 24, 2020)
http://publichealth.lacounty.gov/media/coronavirus/docs/HOO/HO

                                17
      On June 18, 2020, D.V. was reported to still be G-tube
dependent. He continued to require oxygen treatment via a nose
cannula at night and “as needed” during the day. He also
continued to require numerous medications and follow-up care
with medical care providers, including specialists in neurology,
cardiology, endocrinology, ophthalmology, and the
gastrointestinal/nutrition department.
G.     The Jurisdictional and Dispositional Hearing
       At the July 8, 2020, jurisdictional and dispositional
hearing, the juvenile court stated that its tentative ruling was to
sustain count b-1. The court found that “we have a child with
severe medical needs in which the parents have, one, failed to
recognize his healthcare needs; and, then, two, failed in the
medical training to provide the health care needs for the minor
child.” In reaching this determination, the juvenile court
observed that Mother had a history of inadequate supervision of
minor children. Further, comments by the hospital staff
demonstrated the parents lacked comprehension of D.V.’s
medical needs. Mother and Father not only continuously
challenged the conclusions of the medical professionals, but also
demonstrated they did not understand D.V.’s required care by
repeatedly asking the same questions. Both parents failed the
required medical training, and Mother failed to enroll in Regional
Center services as recommended by DCFS.
       Mother and Father argued that they understood D.V.’s
medical needs; DCFS did not make efforts to re-train them; and
DCFS did not demonstrate that Mother and Father could not

O_Coronavirus_LicensedFacilities_04.24.20.pdf [as of Jan. 28,
2021].

                                18
pass the 12-hour training if it was administered a second time.
Instead, DCFS “created a situation where the parents cannot
even engage in this second 12-hour test because they ceased all
in-person contact with the child.” Mother also argued that DCFS
failed to carry its burden to show there were no reasonable
means to prevent removal because, for example, an after-care in-
home caregiver was available who would have made removal
unnecessary. Father’s counsel acknowledged that Covid-19
“caused a lot of problems for everybody and especially [DCFS],”
but argued DCFS’s efforts were inadequate nonetheless.
       The juvenile court adopted its tentative ruling, sustaining
count b-1 of the petition, finding “there are no reasonable means
by which the child’s physical health can be protected” without
removal and that DCFS “made reasonable efforts to prevent
removal but there are no services available to prevent further
detention.” (Italics added.) The court ordered D.V. removed from
Mother and Father and suitably placed under the care and
supervision of DCFS. Mother and Father were ordered “to
complete parenting programs and to obtain medical training to
meet the health care needs of the minor child.”
       Mother and Father timely appealed the July 8, 2020,
dispositional order.
                          DISCUSSION
A.    Legal Standard and Standard of Review
      To remove a child from parental custody, the juvenile court
must find by clear and convincing evidence that one of five
grounds exists pursuant to section 361, subdivision (c). (In re
V.L. (2020) 54 Cal.App.5th 147, 154.) Of relevance here, “[o]ne
ground for removal is that there is a substantial risk of injury to
the child’s physical health, safety, protection or emotional well-

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being if he or she were returned home, and there are no
reasonable means to protect the child.” (Ibid., citing § 361, subd.
(c)(1).)8
       “A removal order is proper if based on proof of parental
inability to provide proper care for the child and proof of a
potential detriment to the child if he or she remains with the
parent. [Citation.] ‘The parent need not be dangerous and the
minor need not have been actually harmed before removal is
appropriate. The focus of the statute is on averting harm to the
child.’ [Citation.]” (In re N.M. (2011) 197 Cal.App.4th 159, 169-
170.)
       The clear and convincing evidence standard “ ‘requires a
finding of high probability. The evidence must be so clear as to
leave no substantial doubt.’ ” (In re V.L., supra, 54 Cal.App.5th
at p. 154.) “ ‘[W]hen reviewing a finding that a fact has been
proved by clear and convincing evidence, the question before the
appellate court is whether the record as a whole contains
substantial evidence from which a reasonable fact finder could
have found it highly probable that the fact was true. Consistent
with well-established principles governing review for sufficiency

      8 Section 361, subdivision (c)(1) provides: “A dependent
child shall not be taken from the physical custody of his or her
parents . . . with whom the child resides at the time the petition
was initiated, unless the juvenile court finds clear and convincing
evidence of any of the following circumstances . . . : (1) There is
or would be a substantial danger to the physical health, safety,
protection, or physical or emotional well-being of the minor if the
minor were returned home, and there are no reasonable means
by which the minor’s physical health can be protected without
removing the minor from the minor’s parent’s physical
custody . . . .”

                                20
of the evidence, in making this assessment the appellate court
must view the record in the light most favorable to the prevailing
party below and give due deference to how the trier of fact may
have evaluated the credibility of witnesses, resolved conflicts in
the evidence, and drawn reasonable inferences from the
evidence.’ ” (Id. at p. 155 [applying the standard of review
articulated in conservatorship matters to a dependency
proceeding], quoting Conservatorship of O.B. (2020) 9 Cal.5th
989, 995-996.)
       Section 361, subdivision (e) also requires the juvenile court
to “make a determination as to whether reasonable efforts were
made to prevent or to eliminate the need for removal of the minor
from his or her home.”
B.     Substantial Evidence Supports the Juvenile Court’s
       Dispositional Order
       Mother and Father argue that DCFS and the juvenile court
failed to make reasonable efforts to prevent removal and thus,
the juvenile court could not find by clear and convincing evidence
that there were “no reasonable means” by which D.V.’s physical
health could be protected without removal. As explained below,
we disagree with each of their arguments.
       1.    Clear and Convincing Evidence Supports the Juvenile
             Court’s Finding of a Substantial Danger to D.V.’s
             Physical Health
       In issuing its order for removal, the juvenile court first had
to find by clear and convincing evidence “that there is a
substantial risk of injury to [D.V.’s] physical health” if he were to
be released to Mother and Father’s care. (In re V.L., supra, 54
Cal.App.5th at p. 154; see § 361, subd. (c)(1).)

                                 21
      As a preliminary matter, it is important to acknowledge
that due to D.V.’s age and the nature of his medical conditions, he
was subject to an ongoing risk of substantial danger to his
physical health. To prevent such danger, it was essential for his
parents to be vigilant in their attentiveness to his daily medical
needs, and to properly execute the procedures necessary to
address those needs.
      We first address Mother’s argument that her prior child
welfare history did not support a finding of a substantial danger
to D.V.’s physical health if he were released to Mother and
Father’s care.
      Mother’s prior child welfare history demonstrated Mother’s
lack of attentiveness to the needs of her children. In May 2017,
her toddler, F.D., escaped Mother’s home and wandered near a
busy street. DCFS advised Mother of necessary steps to ensure
F.D. did not leave the apartment unattended again. However,
the next month, F.D. was found alone in a supermarket parking
lot. The juvenile court was permitted to rely on this history as
evidence that Mother would not be sufficiently attentive to D.V.’s
medical needs. (See In re N.M., supra, 197 Cal.App.4th at p. 170
[in considering evidence of parental inability to provide proper
care for a child for purposes of a removal order, “[t]he court may
consider a parent’s past conduct as well as present
circumstances”].) However, this was not the only evidence upon
which the juvenile court relied.
      The record established that Mother and Father were
incapable of meeting D.V.’s specialized medical needs. For
example, medical professionals repeatedly voiced concern, based
on their observations, that Mother and Father failed to
comprehend how to properly care for D.V. Indeed, during their

                                22
12-hour training sessions in February 2020, Mother and Father
made feeding tube errors, medication errors, and errors in
administering oxygen, revealing that D.V.’s necessary care was
too complex for either of them to manage adequately. Mother
and Father also exhibited questionable judgment by failing to
take action when D.V. gagged and when his nose cannula fell
from his nose. Father demonstrated poor judgment by engaging
in rough play with D.V.
      Additionally, the evidence in the record demonstrated that
Mother and Father repeatedly denied the extent of D.V.’s medical
needs. Notwithstanding several educational and training
sessions with the hospital, on April 16, 2020, Mother and Father
continued to express doubt that D.V. could not be bottle fed safely
or that he needed oxygen. On more than one occasion, they also
accused the hospital of lying to them.
      We also disagree with Mother and Father’s argument that
D.V.’s improved health at the time of the dispositional hearing
weighed in favor of releasing him to the parents. The record does
not show his improvement rose to such a level that his parents
would have been capable of caring for him. Although D.V. no
longer needed continuous oxygen during the day, he still required
oxygen throughout the night and sometimes during the day. His
other serious medical conditions persisted, and he required
several follow-up appointments for specialized care with
neurology, cardiology, endocrinology, ophthalmology and the
gastrointestinal/nutrition departments.
      Accordingly, clear and convincing evidence supported the
juvenile court’s determination that there was substantial danger
to D.V.’s physical health if he were to be placed with his parents.

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      2.     Substantial Evidence Supports the Juvenile Court’s
             Finding That DCFS Made Reasonable Efforts to
             Prevent Removal
       Before ordering removal, the juvenile court must determine
if “reasonable efforts were made to prevent or to eliminate the
need for removal.” (§ 361, subd. (e).)
       In addressing “reasonable efforts” in its May 11, 2020,
jurisdictional and dispositional report, DCFS noted that at the
detention hearing on March 11, 2020, the juvenile court found
that reasonable efforts had been made to prevent the need for
removal. DCFS also noted that on March 11, 2020, Mother and
Father were provided with “low/no cost service treatment
referrals”; on April 16, 2020, a DCFS investigator interviewed
both parents; on April 20, 2020, a DCFS investigator received
D.V.’s medical records; and on May 5, 2020, a child and family
team meeting was scheduled to take place via teleconference with
the parents.9
      Prior to the March 11, 2020, detention hearing, the hospital
and DCFS made reasonable efforts on several occasions to
educate and train Mother and Father about D.V.’s medical needs
and how to care for him. Between September 2019 and January
2020, the parents participated in at least four such educational
and training sessions offered by the hospital to educate them
about D.V.’s medical conditions, his past treatment, plans for his
future treatment, and G-tube feeding. (See In re H.E. (2008) 169
Cal.App.4th 710, 725 [DCFS is entitled to rely on services

      9The record does not reflect whether the child and family
team meeting took place or what was discussed during the
meeting.

                               24
provided by outside sources in demonstrating “reasonable
efforts”].)
       Thereafter, DCFS became involved and not only
communicated with the hospital staff concerning the parents’
progress, but also reinforced with the parents that it was
important that they demonstrate they were capable of caring for
D.V. For example, on January 30, 2020, DCFS met with Mother
and inquired as to her progress relating to G-tube feeding
training and her understanding that D.V. required oxygen.
Mother responded that she would participate in another G-tube
training. DCFS also reached out to Father after the HSW
reported concern that Father was not adequately engaged in
training. Father thereafter confirmed he would participate in
future trainings.
       After D.V. underwent the G-tube procedure, on February
12 and 13, 2020, a nurse demonstrated G-tube feedings and
medication administration for Mother and Father.
       Then, on February 16, 2020, the hospital hosted another G-
tube training session for the parents. On February 18, 2020,
each parent participated in a 24-hour hands on training session,
during which a nurse prompted them on how to care for D.V.
Shortly thereafter, each parent also participated in a 12-hour
independent care training session.
       Notwithstanding each of these sessions, Mother and Father
argue “reasonable efforts” to train them were not made because
during the four months between the detention hearing on
March 11, 2020, and the dispositional hearing on July 8, 2020,
DCFS did not facilitate further training related to D.V.’s medical
needs. However, due to the Covid-19 pandemic and
governmentally-mandated social distancing, DCFS limited its in-

                               25
person services, and the Governor and the Los Angeles County
Department of Public Health issued orders requiring healthcare
facilities to limit or prevent non-essential access. As Father’s
counsel acknowledged, Covid-19 “caused a lot of problems for
everybody and especially [DCFS].” Considered in context, at a
time when an unprecedented global pandemic was causing wide-
spread disruption to delivery of health care and other essential
services, we cannot find it was unreasonable for DCFS or the
medical professionals to delay in providing further in-person
training prior to the July 8, 2020, dispositional hearing.
       Mother and Father suggest training could have been
provided by video. The evidence, however, demonstrates that
remote training would have been inadequate to ensure Mother
and Father were capable of providing D.V. with the care he
required. Throughout their prior in-person training, Mother and
Father seemed to comprehend what was told to them. However,
when it came to personally executing tasks necessary for D.V.’s
care, they lacked the knowledge and skills to do so. As Mother’s
counsel acknowledged at the dispositional hearing, the 12-hour
training “necessitate[s] contact with the child.” Moreover, given
their history of making errors in caring for D.V., Mother and
Father not only required training, but an opportunity to
demonstrate in a hands-on environment that they could properly
care for D.V. Mother and Father have not shown that doing so by
video would have been adequate.
       Reasonable efforts to prevent removal “need only be
reasonable under the circumstances, not perfect.” (In re H.E.,
supra, 169 Cal.App.4th at pp. 725 [tribal social worker facilitated
numerous services and made reasonable efforts to arrange a
psychological evaluation, which could not be timely completed

                                26
due to a lack of funding sources]; cf. In re Ashly F. (2014) 225
Cal.App.4th 803, 809-810 [finding removal was not supported by
substantial evidence where DCFS did not describe the reasonable
efforts it pursued to prevent removal, and the record contained
evidence of reasonable means that could have been considered].)
The record contains substantial evidence supporting the juvenile
court’s finding that reasonable efforts had been made to provide
the medical training required to permit the parents to care for
D.V. in the home.
       3.     Clear and Convincing Evidence Supports the Juvenile
              Court’s Finding That No Reasonable Means Were
              Available to Prevent the Need for Removal
       Finally, in ordering removal, the juvenile court was
required to find by clear and convincing evidence that there were
“no reasonable means” to protect D.V. absent removal. (§ 361,
subd. (c)(1).)
       Mother and Father argue assistance from the maternal
grandmother or an in-home nurse would have obviated removal.
However, Mother and Father have not demonstrated the
maternal grandmother or an in-home nurse could have provided
sufficient assistance. Although the maternal grandmother was
supportive of Mother, she lived in Las Vegas, Nevada, and there
was no indication that she intended to move. There is no
evidence the maternal grandmother would have proved proficient
in addressing D.V.’s complex medical needs. As to the in-home
nurse, the HSW made provisions for an eight-hour in-home
nurse, leaving 16 hours each day when the parents would have
been solely responsible for D.V.’s care. There is no evidence to
suggest that it would have been feasible or reasonable to provide
D.V. with a 24-hour, seven-days-a-week, in-home nurse,

                               27
especially given the limitations and strain on healthcare
resources caused by the Covid-19 pandemic.
       Further, the juvenile court’s order removing D.V. from his
parents was premised in part on Mother’s and Father’s denial of
D.V.’s specialized medical needs. As described above,
notwithstanding multiple educational and training sessions, in
April 2020, Mother and Father continued to doubt the medical
professionals and believed they had a better understanding of
D.V.’s medical needs than the professionals did. The record
amply demonstrates reasonable efforts by DCFS and the medical
professionals to correct Mother’s and Father’s erroneous opinions.
Despite all the counseling they received, they remained unable to
understand or acknowledge the gravity of D.V.’s medical needs.
       At the time of the dispositional hearing, due to the
conditions related to the Covid-19 pandemic, it was not feasible to
provide the parents with further in-person medical training to
ensure D.V. would be safe in their care. The parents had
demonstrated they were not capable of providing the complex
medical care D.V. required. The record as a whole contains
substantial evidence from which a reasonable fact finder could
find it highly probable that D.V. faced a substantial danger to his
physical health, and that there were no reasonable means to
protect him absent removal.

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                          DISPOSITION
      The juvenile court’s July 8, 2020, dispositional order is
affirmed.
      NOT TO BE PUBLISHED

                                           FEDERMAN, J.*

We concur:

             CHANEY, J.

             BENDIX, Acting P. J.

      *Judge of the San Luis Obispo County Superior Court,
assigned by the Chief Justice pursuant to article VI, section 6 of
the California Constitution.

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