Court Opinion

ID: 6327891
Source: CourtListenerOpinion
Date Created: 2022-03-29 19:02:48.549524+00
Date Added: 2024-06-11T09:22:32.462358
License: Public Domain

Filed 3/29/22 In re M.C. CA3
                                           NOT TO BE PUBLISHED
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 This opinion has not been certified for publication
or ordered published for purposes of rule 8.1115.

                  IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA
                                      THIRD APPELLATE DISTRICT
                                                         (Yolo)
                                                            ----

    In re M.C., a Person Coming Under the Juvenile                                             C094548
    Court Law.

    YOLO COUNTY HEALTH AND HUMAN                                                  (Super. Ct. No. JV2020222)
    SERVICES AGENCY,

                    Plaintiff and Respondent,

             v.

    C.C.,

                    Defendant and Appellant.

            C.C., mother of the minor (mother), appeals from the juvenile court’s order
finding the Yolo County Health and Human Services Agency (Agency) provided her with
reasonable services. (Welf. & Inst. Code, §§ 362.1, 366.21, 395.)1 Mother claims she

1    Undesignated statutory references are to the Welfare and Institutions Code.

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was not provided with in-person visitation, or timely and appropriate assistance with
housing and medical training related to the care of, the medically fragile minor. We will
affirm the juvenile court’s judgment.
                                     BACKGROUND
       “On March 4, 2020, due to the outbreak of the COVID-19 virus, Governor Gavin
Newsom declared a state of emergency. On March 11, 2020, the World Health
Organization (WHO) declared COVID-19 a pandemic. On March 19, 2020, Governor
Newsom issued an executive order directing all Californians not providing essential
services to stay at home.” (In re M.P. (2020) 52 Cal.App.5th 1013, 1016.) In recognition
of the ongoing crisis, the Judicial Council promulgated an emergency rule meant to
address visitation in juvenile dependency proceedings, which would expire 90 days after
the lifting of the state of emergency related to COVID-19. (See In re M.P., at
p. 1017; Cal. Rules of Court, appendix I, Emergency Rules Related to COVID-19, rule
6(d).) However, the COVID-19 state of emergency endured.
       In October 2020, as the pandemic raged on, the minor M.C. was born prematurely
at 28 weeks gestation and admitted to the neonatal intensive care unit (NICU). The
medically fragile minor was initially diagnosed with chronic lung disease and ventricular
septal defect (VSD), requiring that she live in a clean, smoke-free environment and that
she be on oxygen support at all times. Two months after her birth, the minor underwent
hernia surgery and was prescribed monthly medications and placed on a special high-
calorie diet. In order to manage the minor’s special medical needs, mother, and S.D.
(father) would need to take the minor to follow-up appointments with a care team which
included a cardiologist, a pulmonologist, a respiratory therapist, a pediatrician, a
registered dietician, an eye doctor, lung clinic staff and Alta Regional Center staff, learn
specific skills and procedures, and return to the hospital frequently to check on the
minor’s lung development and overall growth.

                                              2
       Despite attempts to educate the parents regarding administering the minor’s
medications and maintaining a smoke-free environment, mother struggled with giving the
correct dosage and failed to schedule an appointment for support services, father was “not
interested,” and both parents “reeked of smoke.” Additionally, mother reported she had
recently moved into father’s home where she was experiencing escalating emotional and
verbal abuse from father. Mother stated father was an alcoholic and became verbally
abusive when he drank. Mother also reported she had been diagnosed some time ago
with anxiety, depression, and post-traumatic stress disorder, but was not taking her
medication on a regular basis. She had a history of methamphetamine use but claimed
she completed drug rehabilitation in January 2019 and has been clean and sober since that
time, despite admitting she smoked marijuana with father on occasion. Her 23-year-old
autistic daughter had been placed in a guardianship with the maternal aunt due to
mother’s methamphetamine use. On October 29, 2020, mother tested positive for
marijuana and amphetamines.
       The social worker spoke with father, who appeared to be under the influence of
alcohol and became aggressive and demanding throughout the interview. Father denied
any domestic violence allegations and claimed he never physically or verbally abused
mother. He also denied having a drinking problem but acknowledged he and mother
drank alcohol and smoked marijuana together.
       The following day, while the social worker was interviewing the parents’
apartment case manager at the father’s complex, she reported that she observed the father
throwing the mother out of the apartment along with all of the mother and minor’s
belongings. When mother attempted to get back into the apartment, father shoved her,
causing her to fall and land on her face. Mother reported father had acted similarly
several times in the past.
       Prior to being discharged from the NICU, a protective custody warrant was issued
placing the minor in the care and custody of Agency due to the parents’ history of

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domestic violence, substance abuse, and neglect, mother’s mental health issues, and the
parents’ inability to properly address the minor’s extensive medical needs. On
November 4, 2020, the juvenile court ordered the minor detained. Following a discussion
about the minor’s medical fragility, including the need to be on oxygen around the clock,
and concerns regarding the risk of exposure to COVID-19 and other viruses, the court
directed the Agency to consult with the minor’s physicians to determine whether in-
person visitation was appropriate. In particular, the court stated, “You may not risk this
child’s life over visitation, you just can’t.” In the meantime, the court ordered 30-minute
visits with the minor while hospitalized and video visitation after discharge pending
further information from the minor’s physicians and continued the matter to review the
visitation schedule.
       The Agency reported the minor was discharged from the hospital on November
5, 2020, and eventually placed with a foster family who specialized in medically fragile
infants and had experience with newborns with chronic lung disorders. The minor’s
neonatologist stated that the minor “should only attend required medical appointment[s]
due to being a high-risk fragile infant with a compromised immune system,” and
“[b]eyond medical visit[s], minimal contact in regards to the number of people and
duration of visits [i]s recommended in light of [the minor’s] placement in Foster Care.”
Based on the doctor’s instructions, the Agency recommended no in-person visits for the
minor “at this time.”
       At the visitation review hearing on November 16, 2020, mother’s counsel
requested video visitation and at least one in-person visit each week, noting the
importance of visitation to reunification. The juvenile court ordered continued video
visits and, at counsel’s request, directed the Agency to provide an update from the
minor’s doctor at every hearing regarding the feasibility of in-person visits and any
possible means of mitigating exposure to the minor. The court emphasized, “I would
very much like the parents to be able to have in-person visits. But again, I can’t risk [the

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minor’s] life. And when you have a baby this compromised, that’s exactly what we’re
doing.”
       The jurisdiction/disposition report stated that while the parents were living
together, not smoking, and using nicotine patches, the Agency was concerned that the
parents were unable to demonstrate an ability to provide a smoke-free environment for
the minor. The parents were both enrolled in an outpatient treatment program but had not
been asked to complete a drug test. Mother claimed there had been only one incident of
domestic violence in her relationship with father. The parents either denied or
downplayed the issue of verbal and emotional abuse in the relationship, and both denied
any substance abuse problems. Mother claimed her positive test for methamphetamine
was a false positive. Father stated he had no drug or alcohol issues and claimed he
smelled of alcohol during a visit because he had been using hand sanitizer. The parents
were participating in three hours of weekly supervised visits with the minor via video
conference.
       On December 9, 2020, minor’s counsel informed the juvenile court that the
minor’s condition had worsened. Her lung functioning had declined, and she was having
breathing issues that required inhaled steroids and albuterol. Despite the doctors’
attempts to wean the minor off of oxygen, the minor was unable to be off oxygen for
even a few minutes at a time. Counsel noted there were concerns regarding the minor’s
feedings, including coughing, aspiration, and reflux during feedings, adding the minor
was currently at an emergency appointment with her gastroenterologist. Minor’s counsel
requested, and the court ordered, that the visitation schedule remain the same due to the
minor’s “fragile and worsening medical condition.”
       On January 11, 2021, the Agency reported mother’s disclosure that father had
been drinking heavily, including during juvenile court hearings and video visits with the
minor, and his verbal abuse was getting worse. Fearing father might hurt her, mother

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moved out of father’s apartment and into a confidential shelter with other victims of
domestic violence.
       The minor required a surgical procedure requiring anesthesia to place a
gastrostomy tube (G-tube) due to multiple feeding issues and concerns regarding
aspiration, tachypnea, and fatigue. The minor was receiving weekly physical therapy to
address her high tone and stiffness, lack of mobility and asymmetric movements, and
early intervention services through Alta Regional Center. The minor’s pediatric doctor,
Kimberly Breneisen, M.D., stated that, due to the minor’s medical condition and plans for
the G-tube placement surgery, the minor should not have contact with anyone outside of
essential medical personnel and her current immediate foster placement who were
already self-isolating. Dr. Breneisen cautioned, “[t]here is no exception to this due to the
pandemic and [the minor’s] lung issues.”
       On January 11, 2021, the juvenile court sustained the petition as amended by
stipulation and took jurisdiction over the minor. The court continued the minor’s out-of-
home placement, ordered reunification services to the parents, and ordered the parents to
attend visits with the minor separately, noting visits would be suspended or terminated if
either parent were found to be disengaged or under the influence during visits. Finally,
the court put the matter over for eight weeks to discuss visitation and ordered the Agency
to provide a written report from the minor’s doctor regarding whether in-person visitation
was appropriate.
       On March 1, 2021, the minor’s Court Appointed Special Advocate (CASA), Kelly
Hargreaves, filed a memorandum with the juvenile court regarding her concerns that
changing video visits to in-person visits might jeopardize the minor’s health. Hargreaves
stated that, according to the minor’s pediatrician, contracting COVID-19 would be
“critical” to the minor’s condition given the minor’s serious health conditions including
chronic lung disease and dependency on oxygen. Hargreaves noted that the minor’s
oxygen level frequently fluctuated thus requiring experienced caregiver intervention.

                                             6
Hargreaves recounted having observed, both in the hospital and in weekly visits,
caregivers had to intervene with life-saving actions such as wiping or suctioning the
minor’s mouth to avoid choking, patting the minor’s back to stimulate her, increasing the
minor’s oxygen, administering albuterol, beginning rescue breathing, and calling 911.
Hargreaves stated that, while the parents had observed these interventions, they had not
performed any of the interventions. Hargreaves added that, while having a pediatric
nurse present during in-person visits could mitigate risks associated with the parents’
inexperience, the risk to the minor of contracting COVID-19 by increasing her time in
public and with her parents in close proximity warranted that visits be continued via
videoconference.
       The March 4, 2021, interim review report detailed the minor’s diagnoses which
included bronchopulmonary dysplasia, developmental delay, abnormal muscle tone,
chronic lung disease of prematurity, dysphagia cerebral palsy, static encephalopathy,
extreme prematurity, ventricular septal defect, patent foramen ovale, anemia of
prematurity, respiratory distress syndrome, congenital heart disease, visual impairment,
immature retina, gastroesophageal reflux/esophagitis, retinopathy of prematurity level 3,
and possible seizure. The minor was oxygen-and G-tube dependent, she was on
numerous different medications, and she required the assistance of medical equipment
including oxygen compressor tanks, a pulse oxygen monitor, a nebulizer, an oral
secretion suction machine, and a feeding pump. Following surgery to insert the G-tube
feeding device, the minor developed an infection which was ultimately treated
successfully. She was taken to the emergency room after having “seizure-like activity”
as captured on her baby monitor and was prescribed anti-seizure medication.
       During an appointment, Dr. Breneisen noted the minor continued to have issues
with her breathing, experiencing desaturation and refluxing and she was at risk of
aspiration and periventricular leukomalacia (PVL), a condition seen in preterm babies
who have experienced a stressful NICU course. She opined that the minor was “clearly

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sick,” and her lungs were “not ‘that great.’ ” She also cautioned that if there were to be
in-person visits, they would have to be in a “very controlled environment in which there
is someone capable of monitoring and managing [the minor’s] oxygen level, ability to
complete a G-tube feeding if she will be visiting for more than two (2) hours or as
needed, and has to know how to suction.” Dr. Breneisen felt a licensed nurse would be
best suited to complete those procedures and the parents would not, unless and until they
received extensive training and felt comfortable completing those tasks. Dr. Breneisen
was gravely concerned about the coronavirus pandemic and stated anyone coming into
contact with the minor must be adequately masked and thoroughly screened, including an
assessment of their current living situation, whether they had come into contact with any
person who was sick, and whether they had had any potential exposure to the virus. The
doctor noted that COVID-19 could be deadly to the minor due to all of her medical
complications.
       Mother and the social worker attended the minor’s medical appointments via
videoconference in February and March 2021. The minor continued to experience
oxygen desaturation and episodes of refluxing, not swallowing properly, and gurgling
causing secretions to build up and placing her at risk of choking. She needed to be
suctioned properly in those instances. She was participating in physical therapy and
cognitive development therapy and had numerous future appointments with specialists
due to her “enormous” medical needs. The neurologist confirmed his diagnosis of
cerebral palsy and reported the minor would need to undergo a magnetic resonance
imaging (MRI) and an electroencephalogram (EEG) and be on anti-seizure medication
for a minimum of two years. The gastrointestinal doctor stated an exception could be
made to allow mother to attend the minor’s appointment to change the G-tube in person
so long as she passed a COVID-19 health screening.
       Mother was reportedly living at a women’s shelter where she was receiving
domestic violence counseling. She was hopeful she could obtain housing through that

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resource. She was also participating in services and receiving monthly psychiatric care.
She engaged in supervised virtual visitation with the minor three times per week. The
Agency reported it was unable to facilitate in-person visits due to the high risk of
jeopardizing the minor’s health and it did not have “the structure in place for [the minor]
to be provided with the level of required medical care during in-person visitation
(suctioning, oxygen management and G-tube management/feedings) at the Agency’s
office.” It was noted that mother did not have any experience with, and had yet to learn
the skills required for, the management of the minor’s medical equipment.
       The Agency was very concerned that, due to the fact that its office was open to the
public where people came and went for various purposes, it could not guarantee the
sterile environment necessary for the minor to have in-person visits. Mother was residing
in a communal living environment where the risk of possible COVID-19 exposure was
high. The Agency was exploring resources to provide mother with hands-on training on
parenting and how to administer medical procedures such as G-tube care, suctioning,
oxygen management, and administration of medication in order to prepare mother in the
event the minor became medically stable enough for in-person visits. The Agency
requested that the juvenile court order mother to complete a psychological evaluation to
determine what additional services would most benefit her, as the visitation service
provider noted mother might have some processing delays and the Agency wanted to
ensure mother was receiving the appropriate services for her particular needs.
       At the visitation review hearing on March 8, 2021, the juvenile court ordered no
in-person visits stating, “I can’t authorize in-person visits, I won’t authorize in-person
visits. It’s too dangerous for this child.” The court ordered further visitation review in
May 2021 and continued the matter for discussion on the request that mother undergo a
psychological evaluation.
       The March 26, 2021, interim review report set forth details of the minor’s
continuing medical issues and concerns from the minor’s various specialists regarding

                                              9
her exposure to infection from COVID-19. The minor’s pulmonologist advised that the
parents would have to limit their exposure risk as much as possible if they were to have
any contact with the minor and opined that any contact at all placed the minor at high
risk. Mother received her first COVID-19 vaccination on March 25, 2021, and was
scheduled to receive her second on April 15, 2021. The Agency was hopeful that, once
fully vaccinated, mother could receive the necessary hands-on training from the minor’s
health care providers.
       At the continued hearing on March 29, 2021, mother’s counsel stated as follows:
“After looking at the report I certainly understand the extreme caution and concern
regarding in-person visits. However, I am asking that the Agency allow for in-person
visits once my client has received her second vaccination . . . scheduled for the 15th of
April.” Mother’s counsel argued mother was “almost done with her vaccination” and
should be allowed the same contact as the minor’s service providers. The juvenile court
ordered the psychological evaluation for mother and declined to allow in-person visits
stating, “[The minor] is a very sick little girl and I do not want anything to happen to
her.” The court added that, before it could feel comfortable allowing mother to care for
the minor, “I need to know that she would be able to do that and I’m going to need a
psychological evaluation to know that . . . . [⁋] I’m glad Mom has gotten her shots or is
getting her shots, gotten one, going to get the next one, so we’re getting closer to perhaps
doing in-person visitation. But the thing that’s stopping me is that if [the minor] gets
sick, looks to me from reading the report, that there’s an extreme likelihood that [the
minor] will die, so it’s just not time yet.” The court continued the matter to revisit the
visitation issue stating, “It seems to me like [the minor] is just not getting to the point
where we’d be comfortable doing this and she needs at least a month or so.” When
mother’s counsel asked if there was anything more mother could do to facilitate in-person
visits, the court responded, “[I]t looks like [mother] is doing what she needs to do. So
one other thing perhaps she could do is if there’s a way that she can isolate herself to

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make sure that she is safe, but getting the vaccination is a good thing. But until and
unless I hear from the doctor that this is safe, there’s nothing she can do. There’s really
nothing she can do. This is [the minor’s] life and in order to keep her safe, we have to
make sure she doesn’t get a respiratory illness, especially COVID, but any kind of illness.
She is so fragile right now.”
       Mother was fully vaccinated by April 2021. She participated in a juvenile court-
ordered psychological evaluation and completed her outpatient drug treatment program.
She continued to reside at the women’s shelter but had been referred to two housing
programs, completed a housing voucher, and was on the waiting list for housing. Mother
was actively searching for an apartment and had submitted several applications for
housing. Mother was also actively participating in or had completed her reunification
services. She continued to attend all of the minor’s appointments by videoconference.
Dr. Breneisen remained concerned about mother’s communal living situation in which
“the variables cannot be controlled” (e.g., sharing space with others who were going in
and out of the shelter) and, despite that mother would eventually be fully vaccinated,
recommended no in-person visits.
       On May 24, 2021, at a visitation review hearing, the Agency informed the juvenile
court that Dr. Breneisen was still recommending no in-person visitation until mother
obtained noncommunal housing. Minor’s counsel expressed concern that “we are going
to run into a reasonable services issue at some point” and requested another hearing in
one month. Mother’s counsel agreed but requested immediate in-person visitation,
noting mother was fully vaccinated and should be allowed the same privileges as service
providers who were required to wash their hands and be vaccinated, masked, and gloved
before being around the minor. Mother’s counsel stated mother was working with her
service providers to secure housing but could not control whether she was accepted after
applying. Further, mother was willing to COVID test and isolate in a hotel provided by
the Agency if necessary. The CASA recommended that in-person visits be postponed

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noting that more information was coming out about people who were fully vaccinated
and then subsequently became infected with the COVID-19 virus. The court denied in-
person visits stating, “I’m still of the opinion that we need to follow what the doctor is
saying. I absolutely cannot risk this child’s life and so one more month we’ll put it
off . . . . [⁋] But with the breathing issues and everything else, it’s just too risky.”
       In June 2021, CASA informed the juvenile court that mother’s communal housing
environment placed her at higher risk of contracting COVID-19. Because the minor
continued to be in extremely fragile health, the CASA deferred to the opinions of the
minor’s pediatrician and caregivers that, notwithstanding mother being fully vaccinated,
the minor’s life “would be seriously jeopardized by mother having physical contact with
the [minor] because she is living in a community setting where the likelihood of a
“vaccination break-through” is more likely.”
       The social worker who attended the minor’s video conference medical
appointments with mother noted a concern that when the doctor discussed medications,
breathing, and reflux, the mother asked unrelated questions. Mother appeared to struggle
with connecting the information she received from the minor’s doctors and specialists.
The more information mother received, the more she seemed to struggle to consolidate
and articulate the information. When the minor had to return to her pulmonologist to
address difficulties in tapering down her oxygen, mother continued to ask unrelated
questions and the doctor had to remind her that the appointment was to address the
minor’s breathing issues. At an appointment to fit the minor with a helmet, mother gave
the orthotist inaccurate information about the minor’s diagnoses.
       The Agency received a May 27, 2021, letter from Dr. Breneisen stating mother
would be permitted to attend the minor’s in-person medical appointments so long as she
completed and passed the COVID-19 screening questions two days prior to the
appointment. However, Dr. Breneisen continued to recommend no in-person visits until
she received further guidance from the Centers for Disease Control and Prevention

                                              12
regarding mother’s living situation. Based on Dr. Breneisen’s letter, the Agency
recommended the juvenile court authorize mother to attend in-person medical
appointments for the minor.
       On June 14, 2021, the social worker spoke with Dr. Breneisen’s medical staff who
stated that Dr. Breneisen recommended in-person visits if mother was fully vaccinated,
masked, and screened, and the visitation site was maintained for safety. The Agency
expressed its concern that the Child Welfare Office would not meet the criteria for a safe
visitation site given that it was a public space and numerous parents were constantly
using the visitation rooms with their children. The Agency felt that in-person visits
should take place only after mother found a safer, more controlled environment in which
to live in order to reduce the minor’s risk of contracting COVID-19. In addition, the
Agency continued to search for the appropriately trained personnel to be present at all
visits to monitor for safety, tend to the minor’s needs, and provide mother with hands-on
training.
       Dr. Breneisen followed up with a letter stating, in light of changes to the state’s
COVID-19 guidelines, she was authorizing in-person visits for mother “when the state
has changed their definitions” and mother was fully vaccinated and in “a stable
environment as to know if there are exposures to infection.” Dr. Breneisen recommended
that anyone visiting the minor should meet the same conditions as well, and that visits
would require the presence of someone “capable of tending to [the minor’s] airway with
suctioning if needed, oxygen management, and G[-]tube feedings if the visit is over 2
hours.” Dr. Breneisen also noted that the Agency would need to provide mother with the
necessary instruction on how to care for a medically fragile child. The Agency
recommended the juvenile court authorize in-person visits once mother “obtains her own
housing and when Dr. Breneisen provides the Agency with [the minor’s] care plan.”
       On June 24, 2021, the Agency requested, and CASA agreed, that the juvenile
court authorizes mother’s in-person attendance at the minor’s medical appointments

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immediately and authorize in-person visits as soon as mother obtained independent
housing and the Agency secured appropriate medical care during the visits. Mother’s
counsel noted that mother had done everything that was asked of her and was doing
everything in her power to obtain housing. Mother was fully vaccinated and willing to
cooperate with all medical requirements. Given that the case was coming up on the six-
month review, counsel requested that the court order in-person attendance at medical
appointments and in-person visits not conditioned on mother finding housing. The court
authorized mother to attend the minor’s medical appointments in person and to begin in-
person visits with the minor after obtaining safe housing.
       The CASA report for July 12, 2021, set forth concerns arising from caregivers and
other professionals that mother’s interactions reflected her lack of understanding of the
minor’s physical conditions and how to treat those conditions. When asked by doctors to
describe the conditions, mother was either unable to do so or made inaccurate statements
despite her participation in nearly every appointment. Additionally, when the minor was
in distress during video visits and the caregiver administered emergency treatment,
mother did not ask or seem to understand what the caregiver needed to do. The CASA
recommended that mother be permitted to have in-person visitation once the Agency
confirmed mother obtained stable, smoke-free, private housing and limited contact with
other individuals in order to reduce the risk of the minor contracting COVID-19 or any
other illness.
       Mother’s psychological evaluation was completed by Wendy McCray, Ph.D. Dr.
McCray diagnosed mother with borderline intellectual functioning and unspecified
affective disorder, noting mother “has difficulty understanding and executing
increasingly complex tasks,” particularly those “that require nonverbal problem solving
and abstract reasoning.” Mother also demonstrated impairment in memory and presented
as “a hands-on learner who would likely do best with demonstration and repetition, rather
than verbal instructions and having to rely on her memory.” Dr. McCray stated that

                                            14
mother was likely to have difficulty with “unexpected, unpracticed crisis situations and
complex decision making.” The doctor opined that, were mother to be the minor’s
primary caretaker, mother would require “specific educated support as to how to handle
various potentially emergency crisis situations” with “respite insofar as she becomes
easily overwhelmed and has difficulty multitasking.”
       The July 12, 2021, status review report stated mother was still residing at a
confidential shelter, but she had received a housing voucher in May 2021 and was
actively searching for housing. Mother was participating in or had already completed her
reunification services, was actively participating in person in the minor’s medical and
developmental appointments and had recently received G-tube training. She was also
receiving additional training because she reportedly struggled to read the minor’s cues
during videoconference visits. Dr. Breneisen provided a referral to Shriners Hospital for
Physical Medicine and Rehabilitation and a list of nursing staffing agencies to help with
training for mother and visitation supervision to ensure the minor’s medical needs were
met during visits.
       At the July 19, 2021, six-month review hearing, mother’s counsel submitted on the
Agency’s recommendation to continue reunification services but argued the Agency
failed to provide reasonable services, arguing there were no in-person visits with the
minor. Counsel acknowledged there were unique circumstances involved but argued the
requirements for in-person visits continually changed, including that mother obtain safe,
stable housing. Counsel argued that mother was held to a different standard than
everyone else and it was not reasonable to allow mother to attend doctor’s appointments
in person but not allow her to attend in-person visits. Counsel further argued the juvenile
court’s determination regarding in-person visits could not hinge on the physician or
anyone else.
       The Agency argued it provided all of the necessary services but did not provide in-
person visits because, after numerous and repeated hearings to review the current

                                            15
situation and based on recommendations from the minor’s doctor, the juvenile court
ordered no in-person visits. The Agency further argued mother began attending the
minor’s medical appointments in person and had been permitted to hold and comfort the
minor during examinations by Dr. Breneisen. The Agency stated it was attempting to
obtain more information regarding in-person visits at a doctor’s office versus in-person
visits at an Agency office, noting the Agency was considering utilizing a special room
that was not used by anyone else and solely dedicated to visits between mother and the
minor. The social worker was diligently working on securing nursing care to be present
during the visits to make sure mother had all the support she would require for a safe visit
and to teach mother how to provide medical care to the minor. The Agency requested
that the court find reasonable services were provided given the minor’s “extreme special
needs, the unusual situation with the COVID pandemic, and the fact that the Court did
review that very issue on a frequent basis.”
       The juvenile court found reasonable services were provided to mother, continued
services to mother as modified in the case plan and terminated services to father. With
respect to visitation, the court ordered in-person visits for mother for one hour per week
once the Agency secured appropriate medical staff to attend the visits, giving the Agency
authority to increase visits. The juvenile court set the matter for another hearing to
review the visitation issue.
                                      DISCUSSION
       Mother contends there was insufficient evidence to support the juvenile court’s
finding of reasonable services. She claims the Agency failed to provide her with in-
person visits with the minor, unreasonably delayed in providing her training regarding
how to care for the minor’s medical needs and failed to timely and diligently assist her in
finding suitable housing other than the home she shared with other victims of domestic
violence.

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       The Agency argues mother should be precluded from raising her claim of
unreasonable services as it is nothing more than a guise for a challenge to the juvenile
court’s visitation orders which mother forfeited for failure to timely appeal. In any event,
the Agency asserts, there was substantial evidence to support the finding of reasonable
services as the visitation order was reasonable under the circumstances and mother was
provided with reasonable medical training and housing assistance. The Agency further
argues any error was harmless because the court ordered six additional months of
services for mother, consistent with the remedy she seeks here on appeal.
       As we explain, mother failed to timely challenge the juvenile court’s various
visitation orders issued on or after the disposition hearing and has therefore forfeited any
challenge to those orders here. With respect to her claim of unreasonable services, there
was sufficient evidence to support the court’s finding that the services provided to her
were reasonable.
       “Reunification services must be ‘designed to eliminate those conditions that led to
the court’s finding that the child is a person described by Section 300.’ (§ 362, subd. (c).)
Accordingly, a reunification plan must be appropriately based on the particular family’s
‘unique facts.’ [Citation.]” (In re T.G. (2010) 188 Cal.App.4th 687, 696-697 (In re
T.G.).)
       “[The Agency] ‘must make a good faith effort to develop and implement a family
reunification plan. [Citation.] “[T]he record should show that the supervising agency
identified the problems leading to the loss of custody, offered services designed to
remedy those problems, maintained reasonable contact with the parents during the course
of the service plan, and made reasonable efforts to assist the parents in areas where
compliance proved difficult . . . .” [Citation.]’ [Citation.] ‘The standard is not whether
the services provided were the best that might be provided in an ideal world, but whether
the services were reasonable under the circumstances.’ [Citation.] ‘The applicable

                                             17
standard of review is sufficiency of the evidence. [Citation.]’ [Citation.]” (In re T.G.,
supra, 188 Cal.App.4th at p. 697.)
       As this court explained in In re T.M. (2016) 4 Cal.App.5th 1214: “In addition to
requiring a court to deny visitation if the child’s safety is at risk, the plain language of
section 362.1, subdivision (a) only requires visitation as frequently as the well-being of
the child allows. Accordingly, if visitation is not consistent with the well-being of the
child, the juvenile court has the discretion to deny such contact. As courts have
explained, ‘well-being’ includes the minor’s emotional and physical health.
[Citations].” (Id. at pp. 1219-1220.) “This reading of the statute is consistent with
dependency law’s guiding principle of the well-being of the child: ‘While visitation is a
key element of reunification, the court must focus on the best interests of the children
“and on the elimination of conditions which led to the juvenile court’s finding that the
child has suffered, or is at risk of suffering, harm specified in section 300.” [Citation.]’
[Citations.]” (Id. at p. 1220.) “[T]he parents’ interest in the care, custody and
companionship of their children is not to be maintained at the child’s expense . . . .” (In
re S.H. (2003) 111 Cal.App.4th 310, 317.)
       An order setting visitation is reviewed for an abuse of discretion (In re Brittany C.
(2011) 191 Cal.App.4th 1343, 1356), which will not be disturbed, “unless the trial court
made an arbitrary, capricious, or patently absurd determination.” (Ibid., citing In re
Stephanie M. (1994) 7 Cal.4th 295, 318.)
A.     Visitation
       Mother asserts that, despite her repeated requests, she was not allowed to have in-
person visits with the minor other than the incidental contact she had once she was
permitted to personally attend the minor’s medical appointments. She argues she was
fully vaccinated and was willing to quarantine, wear full protective gear, and test before
each visit, but was nonetheless denied in-person visits and contact-based primarily on the
possible risk of COVID-19 transmission. She further argues she should have been

                                              18
afforded contact to the same extent the minor’s medical providers and foster parents were
allowed, and denial of that right was an arbitrary restriction on her ability to reunify with
the minor. We find no merit in these claims.
       As a preliminary matter, the Agency provided visitation to mother consistent with
the juvenile court’s visitation orders throughout the proceedings. As previously
discussed, mother did not timely challenge those visitation orders. In any event, we will
proceed with a discussion of the origin and propriety of the no in-person visitation orders.
       The record is replete with examples of the minor’s medical fragility, including
numerous issues related to her premature birth, respiratory distress syndrome, congenital
heart disease, visual impairment, reflux/esophagitis, and seizures. She was oxygen-and
G-tube dependent and required numerous medications and medical equipment and staff
trained to use that equipment. Given the minor’s numerous and serious medical issues
and her compromised immune system, exposure to and contact with other people and
environments, particularly during the global COVID-19 pandemic, placed her at great
risk of contracting a life-threatening virus or condition.
       The minor was admitted to the NICU where she remained under the care of a
registered nurse for two months. At the detention hearing, the juvenile court directed the
Agency to consult with the minor’s physicians to determine whether in-person visitation
was appropriate noting, “You may not risk this child’s life over visitation, you just can’t.”
The court continued the matter but ordered video visitation pending further information
from the minor’s physicians.
       When making its visitation orders throughout the dependency proceedings, the
juvenile court was provided with and considered the opinions and recommendations of
the minor’s many physicians and medical specialists. For example, upon the minor’s
discharge from the hospital in November 2020, the minor’s neonatologist recommended
that the minor “should only attend required medical appointment[s]” due to her
compromised immune system and have “minimal contact in regards to the number of

                                             19
people and duration of visits” in light of her placement in foster care. After considering
that recommendation, the court ordered video visits only stating, “I would very much like
the parents to be able to have in-person visits. But again, I can’t risk [the minor’s] life.
And when you have a baby this compromised, that’s exactly what we’re doing.”
Similarly, when the court was informed in early-December 2020 that the minor’s lung
functioning had declined, she was having breathing issues, she could not be weaned off
of the oxygen, and she was experiencing coughing, aspiration, and reflux during feedings,
the court ordered that visitation remain the same due to the minor’s “fragile and
worsening medical condition.” In January 2021, the minor’s pediatrician stated that the
minor required surgery to place a G-tube to address multiple issues and concerns and
that, without exception, the minor should not have contact with anyone other than
essential medical personnel and her foster family members (who were already self-
isolating) due to the COVID-19 pandemic and the minor’s lung issues. The court
continued video visits for further review in eight weeks and ordered the Agency to obtain
a report from Dr. Breneisen regarding the appropriateness of future in-person visitation.
In the meantime, however, mother attended all of the minor’s appointments by
videoconference, including appointments with cardiology, neurology, and pediatrics.
       Dr. Breneisen continued to recommend no in-person visits due to the minor’s
serious medical issues and the potential to become exposed to serious health risks
including the COVID-19 virus. She urged that, even if the parents were fully vaccinated
and practiced all necessary precautions, in-person visits should not occur unless there was
someone such as a licensed nurse present who was capable of monitoring and managing
the minor’s oxygen levels, completing G-tube feedings, suctioning whenever necessary,
and addressing any and all emergent medical issues. The Agency reported it did not have
the structure in place to provide the required medical personnel during in-person visits
and was, therefore, unable to facilitate in-person visits due to the high risk of jeopardizing
the minor’s health. The Agency had further concerns that mother was residing in a

                                              20
communal living environment where the risk of COVID-19 exposure was high, and that
it could not guarantee a sterile environment for in-person visits in its offices due to the
fact that members of the public came and went on a daily basis. The juvenile court
continued to deny in-person visits due to the risk of illness or death to the minor stating,
“I can’t authorize in-person visits, I won’t authorize in-person visits. It’s too dangerous
for this child.” However, the court held regular visitation review hearings to discuss the
issue.
         In March 2021, it was the minor’s pulmonologist who opined that any in-person
contact placed the minor at high risk and advised that the parents limit their own
exposure risk as much as possible if they were to have any contact with the minor. The
juvenile court ordered mother to complete a psychological evaluation to determine
whether mother had some processing delays and what additional services might assist her
in that regard and denied in-person visits. The court acknowledged mother was in the
process of getting vaccinated against COVID-19 but noted that “if [the minor] gets sick
. . . there’s an extreme likelihood that [the minor] will die.”
         By April 2021, mother was fully vaccinated against the COVID-19 virus.
However, her communal living situation continued to concern Dr. Breneisen, who
recommended no-in person visits. At a hearing on May 24, 2021, after mother stated to
the juvenile court that she was willing to COVID test and isolate in a hotel, if necessary,
the court denied in-person visits stating, “I’m still of the opinion that we need to follow
what the doctor is saying. I absolutely cannot risk this child’s life and so one more
month we’ll put it off . . . . [⁋] But with the breathing issues and everything else, it’s just
too risky.” (Italics added.)
         In late-May 2021, Dr. Breneisen recommended that mother be permitted to attend
the minor’s medical appointments in person with the caveat that she pass a COVID-19
screening test two days prior to the appointment. The following month, the juvenile court
followed the recommendation and authorized mother to attend the minor’s appointments

                                              21
in person. Once mother began to attend those appointments in person, she was permitted
to hold and comfort the minor.
       In June 2021, Dr. Breneisen authorized in-person visits so long as mother was
fully vaccinated and in a stable environment, someone medically qualified was present to
tend to the minor’s medical issues, and mother was provided with the instruction
necessary to care for the medically-fragile minor. Both the Agency and the CASA
agreed and requested that the juvenile court do so as soon as mother obtained
independent housing and the Agency secured appropriate medical personnel to administer
care during the visits. The Agency was looking into options to keep the minor safe, such
as using a dedicated room at its offices for visits involving the minor in order to minimize
exposure, and the social worker was working on securing an appropriate medical
provider to be present during visits and teach mother how to care for the minor. The
court authorized mother to begin in-person visits once she obtained noncommunal
housing and the Agency secured appropriate medical staff.
       Mother argues the denial of in-person visitation was arbitrary given that the minor
was being seen by numerous providers and her foster caregivers. She surmises that there
could be no reason to prohibit one more person–mother–from having contact with the
minor, particularly if mother was fully vaccinated and COVID tested prior to each visit,
wore full protective gear, and quarantined. Mother further argues that the Agency failed
to hire nursing staff to be present during in-person visits and its claim that it did not have
nursing support available amounted to a failure to provide reasonable services. We are
unpersuaded by either argument.
       The record makes plain that the minor required care by someone with specific
knowledge and experience to monitor and address the minor’s oxygen levels, G-tube
feedings, suctioning, and any and all emergent medical issues arising as a result of the
minor’s medically fragile condition. Mother does not point to any evidence, and there is
nothing in the record to suggest, that the Agency was not making reasonable efforts to

                                              22
identify individuals who were both qualified and available to undertake the task on a
regular basis, particularly during the worldwide COVID-19 pandemic.
        We note that, in response to the ongoing pandemic, the Judicial Council
promulgated Emergency Rule 6(c)(7)2 which provided for child welfare agencies “to
determine the manner of visitation to ensure that the needs of the family are met” and
required that “[a]ll changes in manner of visitation . . . must be made on a case by case
basis, balance the public health directives and best interest of the child, and take into
consideration whether in-person visitation may continue to be held safely.”
        Acknowledging the importance of family time for the well-being of the parents
and the child, particularly during times of crisis, Rule 6(c)(7) provides that “[v]isitation
may only be suspended if a detriment finding is made in a particular case based on the
facts unique to that case.” Rule 6(c)(7) further provides that such detriment finding
cannot be based solely on “the existence of the impact of the state of emergency related
to the COVID-19 pandemic or related public health directives.”
        Here, several of the minor’s physicians made clear that limiting the amount of
contact between the minor and others was imperative and that any contact placed the
minor at risk. Contrary to mother’s assertion that the risk to the minor was nothing more
than theoretical, the minor was not only in danger of exposure to viruses (including
COVID-19), illnesses, smoke, and other airborne threats but also perils associated with
the minor’s numerous and unique health issues and the potential inability of those around
her to respond to her emergent medical needs.
        Even assuming, as mother argues, that in-person visits could have been facilitated
with appropriate COVID protections, perfection in services is not required. (Elijah R. v.
Superior Court (1998) 66 Cal.App.4th 965, 969; In re Misako R. (1991) 2 Cal.App.4th

2   Further rule references are to the Judicial Council Emergency Rule.

                                              23
538, 547.) We find no abuse of discretion in the juvenile court weighing mother’s desire
for in-person visits against the dangers associated with potential exposure to people and
environments, including the risks associated with the COVID-19 pandemic and the
minor’s unique medical needs. (See In re R.R. (2010) 187 Cal.App.4th 1264, 1284
[court’s visitation order balancing the rights of the parent with well-being of minor is
reviewed for an abuse of discretion].)
       Mother argues the juvenile court improperly delegated the decision regarding
whether in-person visits should occur to the minor’s pediatrician. Not so. As a
preliminary matter, mother’s argument is in reality a challenge to the court’s visitation
order, not the Agency’s provision of services, and is therefore forfeited as discussed at
the outset of this opinion. In any event, it is abundantly clear from the record that the
juvenile court carefully considered the issue of in-person contact between mother and the
minor each time the issue was raised. For example, when mother’s counsel noted mother
was fully vaccinated and was willing to COVID test and isolate in a hotel before each
visit, the court stated, “I’m still of the opinion that we need to follow what the doctor is
saying. I absolutely cannot risk this child’s life and so one more month we’ll put it off.
. . . [⁋] But with the breathing issues and everything else, it’s just too risky.” In each
instance, the court denied in-person visits only after considering information from the
Agency and recommendations from medical professionals that in-person visits could be
harmful if not fatal to the minor and contrary to the minor’s well-being.
       Finally, mother repeatedly claims the lack of in-person visitation denied her the
opportunity to have a relationship or reunify with the minor. Mother was not denied
visitation. From the start of the proceedings, she attended videoconference visits with the
minor regularly. She was also permitted to attend all of the minor’s medical
appointments virtually and was then eventually permitted to attend appointments in
person, where she was permitted to hold and comfort the minor.

                                              24
         There is substantial evidence to support the juvenile court’s finding of reasonable
services with regard to visitation.
B.       Training
         Mother asserts the Agency unreasonably delayed in providing her the training
necessary to care for the minor. She argues the Agency’s inability to provide someone
with sufficient medical experience and training to provide support during in-person visits
was unreasonable and the Agency failed to consider viable options such as having the
foster care parents or respite care providers available during visits. We are not
persuaded.
         From the start, Dr. Breneisen was adamant that in-person visits would need to be
handled by someone such as a licensed nurse who was capable of monitoring and
managing the minor’s oxygen levels, completing G-tube feedings, and suctioning. The
minor also required monthly medications and a special diet and would have numerous
appointments with doctors and specialists throughout her life. Dr. Breneisen felt the
parents would need to receive extensive training and feel comfortable completing those
tasks.
         Before the juvenile court authorized mother to visit or attend the minor’s
appointments in person, the Agency explored resources to provide mother with hands-on
training on how to administer the necessary medical procedures in order to prepare her in
the event the minor became medically stable enough for in-person visits. Mother actively
participated by video in all of the minor’s medical and developmental appointments,
where she observed experienced caregivers giving intervening life-saving actions such as
increasing the minor’s oxygen, suctioning her mouth, administering albuterol, and rescue
breathing but at times did not seem to understand what was needed to assist the minor.
However, during video visits, mother experienced some processing delays, struggled to
consolidate, and articulate the information provided by the minor’s physicians and
specialists, asked unrelated questions during appointments, and had to be reminded about

                                              25
the focus of the appointment, and gave the orthotist inaccurate information about the
minor’s diagnoses.
       Caregivers and other professionals expressed concern that mother’s interactions
reflected her lack of understanding of the minor’s medical conditions and how to treat
those conditions. In order to address those issues and determine how best to provide
services to help, mother underwent a court-ordered psychological evaluation which
revealed she had borderline intellectual functioning and difficulty understanding and
executing increasingly complex tasks, and she demonstrated impaired memory and
became easily overwhelmed. The evaluator concluded that mother was likely to have
difficulty with “unexpected, unpracticed crisis situations and complex decision making”
and would require specific education and support on how to respond to emergent crisis
situations. By July 2021, the juvenile court authorized, and the Agency arranged for
mother to attend medical appointments in person. She also received G-tube training
during which she was given the opportunity to practice and ask questions. Because
mother struggled to read the minor’s cues during videoconference visits, the Agency also
provided her with additional training.
       Given the medically-fragile minor’s unique medical needs, and the ongoing risks
associated with the pandemic, the training services provided were reasonable under the
circumstances. (In re M.F. (2019) 32 Cal.App.5th 1, 14; In re T.G., supra,
188 Cal.App.4th at p. 697.) The juvenile court’s finding of reasonable services with
respect to training is supported by substantial evidence.
C.     Housing
       Finally, mother claims the Agency failed to timely or diligently assist her in
finding noncommunal housing. We disagree.
       Mother was referred to a confidential shelter, a communal living environment for
survivors of domestic violence, in early January 2021. Mother continued to reside at the
shelter as of May 2021 but had been referred to two housing programs (one of which was

                                            26
assigned to an intensive case manager), completed an application for a housing voucher,
and was on the waiting list for housing. She was actively searching for an apartment and
had submitted several applications for housing, and she ultimately received a Section 8
housing voucher at the end of the month. As mother’s counsel informed the juvenile
court on May 24, 2021, mother was working with her care providers to secure housing.
       Mother claims the Agency and the juvenile court improperly denied her in-person
visitation based on her communal housing, arguing the decision was premised on
impermissible prejudice and speculation that survivors of domestic violence are more
likely to engage in risky behavior, placing them at risk of COVID-19 exposure, that there
was a voluminous number of other residents in the shelter, and that those other residents
came and went from the shelter. We reject mother’s first assertion outright as there is not
a hint in the record that the housing concerns of either the Agency or the court had
anything to do with a presumption of risky behavior by domestic violence survivors. We
note that the later two assertions, assuming they are true, do not represent prejudice or
speculation; rather, they represent a reasonable concern that mother was not the only
person living in the shelter and that the comings and goings of the other residents raised
the risk of exposure by mother and thus to the minor if in-person visits were authorized.
       As set forth more than once in this opinion, the Agency’s provision of services,
training, housing assistance, and visitation was to a great extent limited by the juvenile
court’s orders and the ongoing pandemic. In the matter of housing assistance, the
Agency provided mother with referrals, assisted her in filling out and obtaining housing
vouchers, and collaborated with other service providers to help find and secure suitable
housing. We have no trouble concluding those efforts were reasonable under the
circumstances.
       There was substantial evidence to support the juvenile court’s finding of
reasonable services.

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                              DISPOSITION
The juvenile court’s order is affirmed.

                                              \s\                ,
                                          BLEASE, Acting P. J.

We concur:

    \s\              ,
HULL, J.

    \s\              ,
HOCH, J.

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