Court Opinion

ID: 5840604
Source: CourtListenerOpinion
Date Created: 2022-01-12 23:02:14.933521+00
Date Added: 2024-06-11T08:43:45.345990
License: Public Domain

Filed 1/12/22 In re D.W. CA4/1
                 NOT TO BE PUBLISHED IN OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions not certified for
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                COURT OF APPEAL, FOURTH APPELLATE DISTRICT

                                                 DIVISION ONE

                                         STATE OF CALIFORNIA

 In re D.W., a Person Coming Under
 the Juvenile Court Law.

 S.D. COUNTY HEALTH & HUMAN                                      D078918
 SERVICES AGENCY,

           Plaintiff and Respondent,                             (Super. Ct. No. EJ3603)

           v.

 V.W. et al.,

           Defendants and Appellants.

         APPEAL from an order of the Superior Court of San Diego County,
Gary M. Bubis, Judge. Affirmed.

         Elizabeth Klippi, under appointment by the Court of Appeal, for
Defendant and Appellant Mother.
         Nicole Williams, under appointment by the Court of Appeal, for
Defendant and Appellant Father.
                                               INTRODUCTION
         When 12-year-old D.W. was admitted to a hospital for severe
abdominal pain and chronic diarrhea, he weighed 42 pounds, appeared
emaciated, and had other physical findings indicating he had experienced
significant malnutrition or starvation over a prolonged period. The
San Diego Health and Human Services Agency (Agency) filed a petition
alleging that D.W. needed the protection of the juvenile court because he was
at substantial risk of serious physical harm or emotional damage based on
his parents’ failure to provide him with medical and mental health care
treatment, their minimization of his low weight, and their conduct in
undermining his medical treatment and treatment providers in his presence.

(Welf. & Inst. Code, § 300, subds. (b), (c).)1
      S.M. (Mother) and V.W. (Father) appeal the juvenile court’s
dispositional order removing D.W. from their custody. They contend the
removal order was not supported by substantial evidence and the juvenile
court failed to ensure reasonable efforts were made to prevent his removal

from their care. We disagree and affirm the order.2
               FACTUAL AND PROCEDURAL BACKGROUND

A.    Background and Prior Child Welfare History3
      1.    First Contact with the Agency
      Mother and Father were both minors when D.W. was born in 2008.
When D.W. was just over two years old, a relative refused to return him to
Mother after a visit because the relative was concerned about drug use in her

1     Further undesignated statutory references are to the Welfare and
Institutions Code.
2     Minor’s appeal was dismissed after his appointed counsel filed a brief
indicating there were no arguable issues. (In re Sade C. (1996) 13
Cal.App.4th 952, 994.)
3     We provide a summary of the family’s prior contact with the Agency to
provide context for the issues on appeal.

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home. The relative contacted the Agency and several unannounced home
visits found marijuana and paraphernalia within D.W.’s reach. Mother
participated in voluntary services with the Agency for four months. She did
not complete the voluntary program, but made enough progress for the
Agency to close the case.
      2.    Second Contact with the Agency and First Dependency Case.
      The Child Abuse Hotline received two referrals in 2012 regarding drug
use in D.W.’s home, domestic violence between the parents, and bruising on
D.W.’s upper arms, buttocks, and legs. Then four-year-old D.W. said, “My
daddy pinched me” because “I wasn’t listen.” D.W. explained that Father told
him to put on a T-shirt and got mad when he could not get it on by himself.
D.W. also demonstrated how the parents smoked “weed” with a “bong.” D.W.
said he felt “crazy when daddy blow smoke in my face.” A child abuse expert
believed most of the bruises were classic pinch marks, but there were also
marks that could be consistent with a blow from a linear object. D.W.
weighed 31 pounds and appeared well-nourished.
      Mother saw D.W.’s bruises after she was out of town for a few days.
Mother previously told Father not to pinch D.W. When asked why she would
leave D.W. with Father if had injured the boy before, Mother said, “My kid is
tough shit. You can spank him and leave red marks on him and he just
laughs.”
      Father initially refused to meet with the social worker and said D.W.
could have bruises from falling on toys. He eventually admitted pinching
D.W. and causing “a couple” of bruises, but said his son had sensitive skin.
He thought D.W. purposefully did not put on the shirt to make him mad.
When the social worker suggested a child that age may need help, Father
said D.W. was smart enough not to need help.

                                       3
      Father admitted he went on crystal methamphetamine binges, but
denied using crystal methamphetamine around D.W. Although Father
conceded that he and Mother used marijuana as D.W. watched, he denied
blowing smoke in D.W.’s face.
      The Agency detained D.W. and filed a petition in October 2012
asserting D.W. came within the jurisdiction of the juvenile court because he
had suffered or was at substantial risk of suffering serious physical harm
based on father’s conduct and both parents’ failure to provide adequate care
due to their substance abuse.
      The court found jurisdiction and ordered D.W.’s placement with his
maternal grandmother. The case plan included counseling for the parents to
address issues of domestic violence.
      Mother participated in services and made progress by employing new
parenting techniques. Father, who was arrested and taken into custody on
unrelated charges shortly after D.W.’s detention, participated in services
while he was in custody. After his release, he engaged in some services, but
he did not participate in individual therapy.
      In May 2013, the Agency believed Father was residing with Mother
even though he was not supposed to reside at that location and was not
granted unsupervised or overnight visitation with D.W. The parents visited
D.W. without authorization, drank alcohol, and did not follow through with
either their services or D.W.’s services. D.W. exhibited increased behavioral
issues, such as using profanity and acting aggressively and defiantly.
      The grandmother asked the Agency to assess other relatives to care for
D.W. She believed she was making things too easy for Mother by caring for
him. Thereafter, D.W. was placed with his uncle.

                                       4
      The court found the parents made some progress with their case plan
and ordered continued services at the six-month review hearing. However, it
also admonished them about the seriousness of the case and expressed
disappointment in their recent actions.
      By the time of the 12-month review hearing, the parents were making
progress in meeting their goals. They were serious about their participation
and appeared to understand how their actions would contribute to the
Agency’s ultimate recommendations. The parents wanted to live together
with D.W.
      D.W. was on target developmentally. His mental health significantly
improved and he was able to process emotions after participating in therapy.
The therapist attributed the change in his behavior, in part, to the home
environment provided by the uncle.
      The court returned D.W. to his parents’ custody in November 2013,
finding they made substantive progress with their case plans. D.W. adjusted
well to returning home.
      Several months later both parents were arrested on charges related to
prostitution. Mother said this was an isolated incident and that she agreed
to prostitute because they were struggling to pay their rent. A family friend
cared for D.W. until Mother was bailed out of jail.
      D.W. liked living with the parents in their new home because he could
go outside and play with friends. A social worker found that food was
available and that the home was a clean and safe living environment. D.W.’s
health was generally good. Mother said she discontinued a steroid prescribed
for D.W. several months earlier because she did not think he needed it. The
social worker advised Mother to consult with a doctor.

                                       5
        By January 2015, the agency recommended terminating jurisdiction.
Although the parents had not participated in all their services, they
demonstrated an ability to provide for D.W.’s needs and to safely parent.
Shortly thereafter, Mother and Father separated. Mother returned from a
weekend away and smelled marijuana in the home. Father admitted he
smoked marijuana because of stress, but he denied doing so in front of D.W.
        After D.W. missed two weeks of school, a welfare check in February
2015 found him well-fed and in clean clothes, but the house was a mess.
Mother said she had used the last of her money to purchase pizza. She gave
various reasons for keeping D.W. out of school including work, car trouble,
and concerns about the impact of weather on the child’s asthma.
        D.W. said he was hungry “all the time,” but he also said that Mother
fixed meals and there was food in the house. D.W.’s school provided him with
food because he came to school hungry. The principal also gathered food and
supplies for the family. Mother agreed D.W. was always hungry even after a
meal.
        Although the Agency was troubled by Father’s relapse and reports of
inadequate food in the home, it continued to recommend terminating
jurisdiction because there was no evidence of a protective issue for D.W. The
court agreed, terminating jurisdiction and services in February 2015.
        3.   Additional Agency Contacts and Professional Referrals
        After D.W. reunified with his parents, the Agency received several
other reports of neglect in 2015 and 2016. However, the allegations were
closed as either unfounded or inconclusive. D.W. and Mother indicated they
had enough food at home. D.W. also said he had plenty to eat when he spent
time with relatives. On one occasion, D.W. was observed with bug bites and

                                        6
decayed teeth. Mother said a doctor had treated the bug bites, but she
admitted she did not take the child to the dentist.
      D.W. saw a primary care physician in October 2017 for asthma. The
doctor referred him to a cardiologist because she was concerned about D.W.’s
low weight and complaints of chest pain. She asked the parents to follow-up
in three months to track D.W.’s weight progress. D.W. had no documented
follow-up care on this issue between 2017 and October 2020.
      D.W. was seen at Children’s Hospital in March 2018 at the age of nine
for suicidal ideation after he attempted to jump from a moving car. Although
mental health resources were provided to the family, the parents did not
follow through with therapy or counseling for D.W.
B.    Current Dependency Case
      1.    Physician Visit for Stomach Pain
      The parents took D.W. to his primary care physician on October 20,
2020 for stomach pain. He had gained less than a pound since his last
primary care visit in 2017. D.W.’s height was that of an average six- or
seven-year-old child rather than a 12-year-old child. Mother said he had a
“terrible appetite” and “eats like a bird.” They said they changed his milk
and food options, but D.W. worried about “getting fat.”
      The doctor said D.W.’s belly was not fat, but appeared distended and
bloated with air and inflammation. She asked the parents to obtain lab tests
that day. Mother wanted to wait because D.W. was upset about receiving
immunization shots. They returned for the lab test about a week later.
When the physician received abnormal lab results on November 3, 2020, she
made an urgent referral to gastroenterology.

                                       7
      2.    Hospitalization
      On November 6, 2020, the parents brought D.W. to the Children’s
Hospital emergency room with complaints of severe abdominal pain and
chronic diarrhea. He appeared significantly malnourished based on his

emaciated appearance, low muscle mass, and digital clubbing.4 D.W.

weighed 42 pounds, which was less than he weighed three years earlier.5 He
was admitted for severe malnutrition and concerns about failure to thrive.
      A gastroenterologist determined that his “profound physical exam
findings” reflected a long-standing disease. She was concerned that the
parents did not seek medical care earlier. A pediatrician with a specialty in
child abuse agreed D.W.’s condition presented an overall picture that was
concerning for long-term malnutrition.
      The parents reported that D.W. had exhibited symptoms of abdominal
pain, bloating, diarrhea and picky eating for at least a year, but his weight
loss occurred only over the previous month. They were not concerned about
his size, saying he was “a small kid who eats a lot.” The parents said D.W.
had seen pediatricians since 2017, but they could not provide any dates or the
names of the doctors.
      D.W. denied physical abuse, but described an isolated life playing
videogames, watching videos, or being on the computer for school multiple
hours per day. He said he ate fast food and breakfast items. Snacks were
available at any time and he denied worrying about his weight or eating.

4      “Clubbed” fingers or toes have “a bulbous enlargement of the tip with
[a] convex overhanging nail.” (Webster’s Medical Dictionary
https://unabridged.merriam-webster.com/medical/clubbed. [As of Jan. 11,
2022], archived at .)
5     A 12-year-old child should weigh at least 80 pounds.

                                       8
      D.W.’s arms and chest were thin and his stomach appeared distended.
However, he showed a medical provider what he believed was belly fat and
described himself as having a “mushed,” “wide” or “chubby” body. D.W.
watched a program about morbidly obese individuals. He was afraid of
gaining so much weight that it would obstruct his breathing and require
surgery. As a result, he only ate snacks on days after having a bowel
movement.
      A psychiatrist determined that D.W. presented with symptoms “seen in
patients with severe malnutrition and starvation.” The effects of starvation
can appear similar to disordered eating behaviors such as anorexia nervosa.
These symptoms can include restricting caloric intake, preoccupation with
food and weight as well as a distorted body image.
      A colonoscopy revealed an intestinal stricture consistent with Crohn’s
disease. The gastroenterologist discussed the diagnosis with the parents and
explained D.W. would require lifelong treatment. Father became defensive
and did not believe the diagnosis. Mother was more receptive, but was
fearful of the medications and upset at the lifelong diagnosis.
      The physician emphasized to the parents the importance for D.W. to
have a strict mechanical soft diet to ease the blockage and to use a
supplemental nutrition beverage. Nevertheless, the next day Father gave
D.W. a “large bacon cheeseburger.” Father told D.W. it was okay to eat the
burger if he chewed a lot. The physician said it was inappropriate and
dangerous to trust a child who had not eaten a full meal for almost a week to
chew the food appropriately without supervision or portion control. Mother
was apologetic. D.W. became upset when the medical providers removed the
burger.

                                       9
      Father yelled at the nursing staff in front of D.W. on several occasions,
saying D.W. was a picky eater and complaining that hospital food “sucks” and
was “worse than jail food.” D.W. refused to eat and mimicked Father’s
sentiments saying the “food sucks.” He received nutrition primarily through
an intravenous nutrition supply.
      Father also said D.W. was lactose intolerant and should not be given a
supplemental nutrition beverage. The gastroenterologist confirmed there
was no evidence that D.W. was lactose intolerant, and she was troubled by
the parents’ resistance to giving him a nutrition supplement. The treatment
team expressed concern that the parents were impeding D.W.’s care and

furthering his refusal to eat.6
      The child abuse pediatrician concluded that D.W. met the criteria for
someone who had experienced torture based on the combined diagnosis for
medical neglect, nutritional neglect, and mental health neglect due to lack of
follow-up. She believed it was unsafe to discharge D.W. to the parents’ care
given their inability or lack of capacity to understand and follow the
treatment plan and their lack of regard as to how their behaviors impacted
his eating and health.
      3.    Agency Initiates Second Dependency Case
      The Agency filed a petition on November 19, 2020, stating that D.W.
needed the protection of the juvenile court as an individual described by
section 300, subdivisions (b)(1) and (c). Count 1 asserted that he suffered or

6       Father also yelled at the nurses for not allowing D.W. to close the
curtains in his room due to concerns about suicidal ideation. D.W. told a
team member “I wanna go home. I’m here against my will. I don’t care if I
die . . . My family can just cremate me.”

                                      10
was at substantial risk of suffering serious physical harm or illness based on
the parents’ willful or negligent failure to provide adequate food, clothing,
shelter, or medical treatment. Count 2 alleged D.W. was suffering or at
substantial risk of suffering serious emotional damage because the parents
failed to seek mental health treatment, minimized his extremely low weight,
and verbally undermined his treatment providers.
      Mother requested a short continuance of the detention hearing. The
court granted the request, but found without prejudice that continued care in
the custody of the parents was contrary to the child’s welfare. The court also
found reasonable efforts had been made to prevent the need for removal of
the child from the home.
      At the continued detention hearing, on November 23, 2020, counsel for
Mother and Father argued that the Agency had not proven a substantial risk
of harm if D.W. were returned to their care. They believed the Agency could
provide services to eliminate the need for removal. Counsel for Mother said
that the diagnosis of Crohn’s disease helped the parents understand what
was going on with D.W. and how to prevent further harm. Mother contended
they had taken D.W. for medical care over the years and he had only lost
weight recently. She was willing to follow all medical and psychological
treatment appointments. Mother’s counsel suggested frequent home checks,
interviews, and providing Facetime communication between D.W. and the
social worker and minor’s counsel upon request. Alternatively, Mother
requested liberal visitation and voluntary services. Father’s counsel joined
Mother’s arguments but, alternatively, requested D.W.’s placement with the
uncle who had previously cared for him.
      The Agency urged the court to follow its recommendations and order
out-of-home care for D.W.’s safety. It maintained the parents had provided

                                       11
no evidence that D.W. received medical care since 2017 even though the
agency asked for documentation.
      The court adopted the Agency’s recommendations with some
modifications. It confirmed its findings that D.W. was as described by section
300, subdivisions (b) and (c) and that continued care in the parents’ home
was contrary to his welfare. It also found that reasonable efforts were made
to prevent or eliminate the need for D.W.’s removal, but that there were no
known services available to prevent further detention. The court commented
that this was a complicated case, physically and psychologically. It noted
that the goal was to reunify D.W. with his parents, but there were “red flags.”
This was a 12-year-old child who weighed only 42 pounds and exhibited signs
of long-term malnourishment. The court believed the parent’s failure to seek
treatment earlier supported a prima facie showing that D.W. would be at
substantial risk if he returned home.
      4.    The Five Months Between Detention and Adjudication
      After the detention hearing, the parents appeared at the hospital
several times for unscheduled or unsupervised visits. A social worker
reported that D.W. was on video calls with Mother and Father “constantly,
all day long.” A staff psychologist discovered that D.W. made a secret sound
when someone came into the room so the parents would stop talking. The
parents also instructed him not to cooperate with nursing staff. Then he
refused to eat because the parents were not visiting. Medical staff thought a
nasogastric feeding tube could be necessary, but the parents refused.
According to the social worker, the parents were unwilling to cooperatively
participate within any acceptable boundaries.
      By December 2020, D.W. was housed in the medical behavioral unit of
the hospital and there was no tentative discharge date. When Mother told

                                        12
D.W. they were no longer allowed to have unsupervised contact, they both
became tearful. D.W. asked to see a social worker and questioned why
supervised visits were required. When the worker explained it was a court
order, he said he understood. He appeared happy, however, about the
possibility of his uncle supervising his visits with the parents. D.W. wanted
to return home and denied a lack of food in the home saying, “I’m the one
that eats the most. I am always eating.” He attributed the malnutrition to
Crohn’s disease.
      Mother denied knowing that D.W.’s primary physician made a referral
to cardiology in 2017 for low weight and chest pain. She said they brought
D.W. to the hospital for concerns about suicidal ideation in 2018 and no one
said anything about his weight or nails. She admitted they missed a therapy
appointment. Mother said she homeschooled D.W. for fifth grade because he
was being bullied. Father conceded they did not take D.W. to a pediatrician
for immunizations between 2017 and 2020 because he did not need to go to
the doctor during that time.
      Mother said D.W. normally weighed 50 pounds. She thought he was
small because she was a teenager when she gave birth and she weighed only
90 pounds. Father also said the family is generally small. Still, the parents
admitted they took D.W. to the doctor in October for rapid weight loss after
Mother noticed D.W. was getting dressed in the closet. They were waiting for
a referral, but brought him to the emergency room for stomach pains. Mother
denied knowing he was admitted to the hospital for severe malnutrition and
failure to thrive.
      In response to assertions that they were undermining medical care,
Mother said a nurse told them they could give D.W. the burger if it was
chewed like soup. Mother claimed she was supervising his chewing when the

                                      13
doctor came in and said he could not have the burger. Father stated that
nurses are bad babysitters and that the child abuse physician’s comments
made the nurses not listen to Father.
      From reviewing D.W.’s medical records, a child abuse expert noted that
he grew well until age six. He had a body mass index around the 50th
percentile and was about 10th percentile on the growth chart. Thereafter,
D.W. stopped getting medical care and only saw a pediatrician one time
between the ages of six and 12. Mother did not follow-up on D.W.’s mental
health issues after he tried to jump out of a moving car. The expert believed
D.W.’s medical neglect, starvation, severe malnourishment, and Crohn’s
disease had gone on so long that he will have long-term consequences.
Additionally, the expert was concerned that the parents undermined D.W.’s
medical providers in front of him, which eviscerated his trust in doctors.
      At a child and family team meeting, D.W. continued to deny he was
malnourished. He said, “I came here because I ate too much. I eat the most
out of everyone. My two favorite foods of all is burgers and Subway.” Father
thought the situation was a “big misunderstanding” and did not feel they
were being heard. When Father asked if Crohn’s disease could present as
malnutrition and starvation, the gastroenterologist said it can lead to mal-
absorption and probably contributed to D.W.’s condition. However, his
clubbed digits showed a severe degree of malnutrition and failure to thrive
that exceeded what they would see with Crohn’s disease.
      Mother thought it would be helpful to have nutrition and medical
education classes. She also thought it would be helpful for a nurse to check
on D.W. Mother thought he would need mental therapy “after all of this.”
She said D.W.’s uncle would be the best choice for a placement option with
her mother as the next option. Mother agreed to participate in services

                                        14
recommended by the Agency. Father also agreed to participate in services if
it helped get his “kid back,” but he did not want to participate if he did not
have to do so. He agreed that placement with the maternal uncle would be
best for D.W. because the uncle had “been through the process” and had cared
for D.W. before.
      The uncle agreed that nutrition classes and education about the
Crohn’s diagnosis would be helpful for the family. The Agency had completed
the home visit required for resource family approval of the uncle’s home and
the uncle was working on the required education programs.
      The Agency concluded there were no reasonable means of protecting
D.W.’s physical and emotional health without removing him from the custody
of his parents. It believed the parents’ rejection of medical evidence and
opinions as well as their lack of understanding and knowledge of D.W.’s
medical conditions could lead to life-threatening consequences. The Agency
also thought D.W.’s life depended on the parents’ understanding and
supporting his medical and mental health conditions and treatment.
      At a hearing in December 2020, the court noted that people felt Father
was trying to intimidate the medical staff. It acknowledged that the parents
were emotional about the case and that the issues were complex. The court
said the attorneys would address those issues at trial and could present
contrary medical opinions. In the meantime, the judge asked Father to
remain civil with the doctors even if he disagreed with them. He asked the
Agency to make exceptional efforts to allow the parents to visit D.W. for
Christmas, but admonished the parents to control their emotions to facilitate
such a visit.
      In January 2021, after Mother and D.W. requested unsupervised and
expanded visits at the hospital, the court modified the order to allow

                                       15
unsupervised visits with the concurrence of minor’s counsel. The court
encouraged the agency to expand visits or to allow unsupervised visits if they
could occur safely.
      D.W. had surgery in February 2021 to remove a portion of his bowel.
He initially did well after surgery, but was transferred to the eating disorder
service when he did not make progress with eating. Discharge planning
included educating the uncle regarding D.W.’s diet, feeding schedule, and
outpatient medical follow-up to ensure he gained weight. The Agency
recommended placement with the uncle because it would allow D.W. to
maintain connections with various family members. The parents and D.W.
agreed.
      Although the parents became more cooperative, the Agency still had
safety and risk concerns because the parents had only participated in
parenting classes and had not yet participated in child abuse group therapy.
It recommended further services for the family. At a hearing in February
2021, the court again admonished the parents to temper their emotions when
dealing with the medical providers. The court emphasized that the case is
about D.W. and that they needed to make sure he receives good care even if
they do not like the doctors.
      D.W. was discharged from the hospital on March 15, 2021 to the care of
his uncle after four months of intense nutritional rehabilitation, psychological
treatment, and treatment for Crohn’s disease. He grew dramatically during
hospitalization. The uncle took two weeks off work to ensure D.W. attended
all necessary medical appointments and ate meals at scheduled times. D.W.’s
maternal grandmother provided care when the uncle returned to work. D.W.
appeared well-adjusted and comfortable in the placement. The uncle
reported that supervised visits with the parents were going well.

                                      16
      In April 2021, D.W. was doing well clinically and was maintaining a
consistent weight around 60 pounds. He was eating three meals a day and
taking nutrition supplements to ensure continued weight gain. The uncle
made sure he finished meals in a timely manner and removed distractions.
      Mother and Father were cooperative and maintained communication
with the Agency. They had nearly completed their parenting classes, but still
had not engaged in all their services. Mother started therapy, but Father
had not completed the psychological evaluation to help the Agency tailor his
services. Neither parent was attending child abuse group therapy sessions.
The Agency recommended that the child remain out of the parents’ care while
they participated in continuing family reunification services.
      5.    Contested Adjudication and Disposition Hearing

      The contested adjudication hearing was held on April 21, 2021.7 The
parents requested dismissal of the petition and denied the allegations of
torture, starvation, and abuse. They asserted that medical records from 2020
showed D.W.’s muscle mass was fine and they believed his digital clubbing
was attributable to the Crohn’s disease and inflammation. Mother and
Father maintained that D.W. lost weight rapidly before his hospitalization.
They denied knowing of a cardiology referral in 2017 and claimed they did
not ignore D.W.’s mental health concerns in 2018. They argued there was no
need for the court’s jurisdiction because they had received sufficient
education to care for D.W.

7     Father’s counsel asked for several continuances based on efforts to
obtain an expert review. After Father’s counsel indicated they would not list
an expert witness, Father requested an additional continuance to obtain a
second opinion from his health care provider. The request was denied due to
the constraints of fast track rules. The court told Father he could continue to
pursue the opinion and raise the issue again.

                                      17
      D.W. also asked for dismissal of the petition. Minor’s counsel, however,
agreed that the Agency had proved the petition based on a pattern of medical
neglect and failure to arrange medical care over six years. After considering
the evidence and the arguments of counsel, the court found by clear and
convincing evidence that D.W. was as described by section 300, subdivisions
(b) and (c).
      Mother testified on the issue of disposition. She said she learned the
importance of well-child exams to make sure a child is healthy and growing.
She understood D.W. was diagnosed with Crohn’s disease, a heart condition,
and anorexia nervosa. She described how she needed to treat and monitor
D.W.’s medical and mental health conditions. Mother said she would take
D.W. to the doctor because Crohn’s disease and mental health are going to be
a big part of their lives.
      Mother said she learned tools in her parenting class to help her
understand how D.W. is feeling and how to involve him in family activities.
Mother was in therapy for her own anxiety and symptoms so she can be more
present for D.W.
      Mother’s counsel asked the court to return D.W. to Mother’s care.
Although the parents were living together, counsel argued the court could
order no unsupervised time with Father. Alternatively, counsel asked for
unsupervised visits for Mother separate from Father so she could help the
uncle with childcare.
      Minor’s counsel, as guardian ad litem, felt the recommendation to
detain D.W. out of his parents’ custody was appropriate. The severity of his
condition caused an increased safety issue and the parents’ initial animosity
toward the medical care providers undermined his ability and willingness to
engage in treatment. Minor’s counsel also noted that this was the second

                                      18
dependency case and Father had not completed a psychological evaluation or
therapy to address the protective issue.
         Although the Agency believed that Mother’s statements about
understanding D.W.’s diagnoses and watching for concerns were a good start,
they did not adequately address how Mother let his issues go on for years
without seeking help. The Agency recommended supervised visits until the
parents could show insight on that issue.
         And after considering the evidence and arguments on the bifurcated
issue of disposition, the court ordered D.W. removed from his parents, stating
it found by clear and convincing evidence that he would be at substantial risk
of harm if returned home and there was no reasonable means to protect him
without removal. The court ordered D.W.’s continued placement with his
uncle.
         Over the Agency’s objections, the court ordered unsupervised visitation
for Mother two times a week for three hours at a time. The court gave the
Agency discretion to allow unsupervised visits with Father and to expand
unsupervised visits for Mother with notice to minor’s counsel. The court
modified the parents’ case plan to require substance abuse testing for 90 days
only and set a special hearing for consideration of whether the plan requiring
a 52-week child abuse program was specifically tailored to the issues

presented in the case.8

8      At the subsequent special hearing, the court ordered a 52-week child
abuse class, which would be specifically tailored for the family after
evaluation. If the evaluators did not believe the service would be
appropriate, the service would be stricken. The notice of appeal was filed
after this hearing, but the parents do not challenge this order in their briefs.

                                        19
                                 DISCUSSION
      The parents do not challenge the court’s jurisdiction finding, but
contend the court’s order removing the child from their custody was not
supported by substantial evidence because the court did not make a proper
finding that reasonable efforts were made to prevent removal of the minor
from their care. We begin with an overview of the general legal principles
and then discuss the court’s findings on disposition.
A. General Principles and Standard of Review
      After a juvenile court exercises jurisdiction over a child pursuant to
section 300, it must hold a disposition hearing to decide where the child
should live while under the court’s supervision. (§§ 360, subd. (d), 361,
362; In re N.M. (2011) 197 Cal.App.4th 159, 169 (N.M.).) “Generally, the
court chooses between allowing the child to remain in the home with
protective services in place and removing the child from the home while the
parent engages in services to facilitate reunification.” (In re E.E. (2020) 49
Cal.App.5th 195, 205 (E.E.).) The court has broad discretion to choose a
disposition that serves the child’s best interest. (In re Nada R. (2001)
89 Cal.App.4th 1166, 1179.)
      Before removing a child from his or her parent, the court must find, by
clear and convincing evidence, that the child would be at substantial risk of
harm if returned home and that there are no reasonable means to protect the

child without such removal.9 (§ 361, subd. (c)(1); E.E., supra, 49 Cal.App.5th

9     The juvenile court may remove a child from his or her parent if the
court finds by clear and convincing evidence that “[t]here 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

                                       20
at p. 205.) The court must also determine whether reasonable efforts were
made to prevent or eliminate the need for removal of the child from his or her
home and state the facts on which its decision to remove the child is
based. (§ 361, subd. (e); see In re D.P. (2020) 44 Cal.App.5th 1058, 1067.) To
assist the juvenile court, the Agency must describe in its social study “the
reasonable efforts [it] made to prevent or eliminate removal.” (Cal. Rules of
Court, rule 5.690(a)(1)(B)(i).) “A removal order is proper if based on proof of
parental inability to provide proper care for the child and proof of potential
detriment to the child if he or she remains with the parent.” (N.M., supra,
197 Cal.App.4th at p. 169.) In determining whether removal from a parent’s
home is necessary, the court may consider the parent’s past conduct as well
as current circumstances. (Id. at p. 170.)
      We review a removal order for substantial evidence. (In re R.T. (2017)
3 Cal.5th 622, 633.) Because section 361, subdivision (c) requires proof by
clear and convincing evidence, we determine “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.” (Conservatorship of
O.B. (2020) 9 Cal.5th 989, 995–996 (O.B.); see also In re V.L. (2020) 54
Cal.App.5th 147, 154–155 [standard of review described in O.B. applies
to removal findings under § 361, subd. (c)].) “In conducting [this] review, [we]
must view the record in the light most favorable to the prevailing party below
and give appropriate deference to how the trier of fact may have evaluated

custody. . . .” (§ 361, subd. (c)(1)), or “[t]he minor is suffering severe emotional
damage, as indicated by extreme anxiety, depression, withdrawal, or
untoward aggressive behavior toward himself or herself or others, and there
are no reasonable means by which the minor’s emotional health may be
protected without removing the minor from the physical custody of his or her
parent” (§ 361, subd. (c)(3)).

                                        21
the credibility of witnesses, resolved conflicts in the evidence, and drawn
reasonable inferences from the evidence.” (O.B., at pp. 1011–1012.)
B. The Court’s Disposition Order is Supported by Substantial Evidence
      In ordering the child removed from the parents pursuant to section 361,
subdivisions (c)(1) and (3), the court made the statutory findings that there
was “a substantial danger to the physical health, safety, protection or
physical or emotional wellbeing of the child, or would be if the child was
returned home. And there are no reasonable means by which the child’s
physical health can be protected without removing the child from the parents’
physical custody.” The court also found that “the child is suffering severe
emotional damage, indicated by anxiety, depression. And [there] are no
reasonable means [by] which [the child’s] mental health may be protected
without removing [the child] from the custody of the parents.” Finally, the
court stated that “[r]easonable efforts have been made to prevent or eliminate
the need for the removal of the child from the home of the parents.”
      Although the court’s statement of findings in support of removal did not
include a fulsome discussion of the facts of the case, it made the necessary
statutory findings in support of removal. Considering the findings in the
context of the entire record, we conclude the court’s findings were supported
by substantial evidence and any failure to state more specific facts on the

record was harmless.10

10    The court received and considered the Agency’s reports including the
detention report, the jurisdiction/disposition report, and the addendum
reports. These reports tracked D.W.’s medical history and progress as well as
the parents’ interaction with the medical professionals and their progress
with services. The court also received D.W.’s growth chart as well as his
stipulated testimony that he thought the case should be dismissed and he
wanted to be with his parents.

                                      22
      The detention report included a discussion of reasonable efforts that
were made to prevent or eliminate the need for D.W.’s removal from the
home. It noted that the Agency provided the parents with counseling, parent
training, and substance abuse treatment in the prior dependency case. The
parents began some services, but did not fully engage or complete those
services after the child was returned to Mother’s care in 2014. The report
identified counseling, case management, and parent training along with
consistent participation in medical care and education about the child’s
Crohn’s disease, eating disorder and mental health issues as services that
could be offered to prevent the need for further detention or facilitate return
of the child.
      The jurisdiction and disposition report identified as “reasonable efforts”
the social worker’s efforts to obtain records and interviews regarding the
underlying facts and to make referrals for services for both D.W. and the
parents. The Agency also undertook concurrent planning efforts for
placement with the uncle at the request of both parents.
      This case is distinguishable from In re Ashly F. (2014) 225 Cal.App.4th
803 (Ashly F.), cited by Mother, where the appellate court reversed a removal
order because the record contained no evidence of reasonable efforts by the
department to prevent removal. The department’s reports merely cited the
statutory language in conclusory fashion without describing its efforts or the
alternatives it had considered or rejected. (Id. at pp. 809, 811.) The parents
here did not cross-examine the social worker or object to the adequacy of the
Agency’s reports regarding reasonable efforts. They did not suggest, as
Mother does on appeal, that she could live with the uncle’s family and the
child as a reasonable alternative to removal. Failure to object at the trial
court forfeits the issue on appeal. (In re A.S. (2018) 28 Cal.App.5th 131, 151;

                                       23
see also Civ. Code, § 3515 [one who “consents to an act is not wronged by

it”].)11
       The court also took judicial notice of the prior findings and orders in
the case. Among those prior findings were those made at the detention
hearing. The court found by a preponderance of evidence that placement out
of the home was necessary because there was a substantial danger to D.W.’s
physical and emotional health and there was no reasonable means to protect
his physical or emotional health without removing him from the parents’
physical custody. The juvenile court stated “this is a complicated case,
physically and psychological[ly].” “This is a 12-year-old who weighs 42
pounds and the problem is not simply that [the child is] underweight, but
that . . . there’s evidence of long-term malnourishment.” The court also
stated that the failure to seek treatment earlier showed the child was at
substantial risk if returned home.
       Although the standard of proof at disposition is higher than at
detention, the severe facts that brought D.W. into the dependency system did
not change between the detention hearing and the adjudication hearing. At
the disposition hearing, the court referred to the case as “horrific” and said in
the context of considering Mother’s request for unsupervised visits, “[t]here’s
a lot going on with [D.W.]”
       The reports and medical evidence provided substantial evidence of
severe malnutrition and significant mental and emotional issues indicating
that D.W. experienced years of medical, nutritional, and emotional neglect by

11    We note that in the prior dependency case, D.W. was placed with the
same uncle after grandmother said she could not continue to care for him.
There is no indication anyone suggested Mother could live with the child in
the uncle’s household, either in the prior case or this one.

                                        24
his parents. Yet they failed to acknowledge his weight loss and other
physical symptoms and did not seek or follow-up on medical care, even when
directed to do so. When D.W. was hospitalized, the parents disagreed with
the diagnosis, discounted concerns regarding his weight, and undermined the
opinions and recommendations of the medical professionals who cared for
him. In the months before the adjudication hearing, the court repeatedly
admonished the parents to cooperate with and be civil with medical staff who
were attempting to care for D.W.
      Further, this is not the parents’ first dependency case. In determining
whether a child may be safely maintained in the parent's physical custody,
the court may consider the parent’s past conduct if there is reason to believe
the conduct will continue. (In re S.O. (2002) 103 Cal.App.4th 453,
461.) Although the facts of this case are different than the prior case because
there was no evidence of bruising or physically abusive discipline, the
severity of D.W.’s malnutrition and the parents’ neglect to provide medical or
mental health care was another form of physical abuse.
      The juvenile court judge was familiar with the family not only from
observing their conduct during this dependency case, but also during the
prior dependency case. As such, the court was in the best position to evaluate
the credibility of the parents’ statements about what they have learned and
the risk to D.W. if he returns home before the parents are ready. It is not
hyperbole to say D.W.’s life depends on the ability of the parents to
understand his medical and nutritional needs and to follow-through with
medical recommendations.
      The evidence showed D.W. made enough physical progress to be
discharged from the hospital, but it was apparent he still faced significant
physical and mental health issues. The parents also made some progress in

                                      25
being more cooperative in the weeks before the hearing. However, the record
shows that the parents have a pattern of not consistently following through
on direction from medical care providers, social workers, or the court.
      As of the time of the adjudication hearing, the parents had not engaged
in all their services. They still minimized the concerns about D.W.’s weight
and disagreed with the assessment of malnutrition due to starvation,
attributing his problems solely to the Crohn’s disease. The Agency believed
the parents “continue to lack insight in regards to the protective issues, the
Agency’s concerns and the seriousness of [D.W.’s] current medical condition.”
The Agency believed this “lack of insight is dangerous for [D.W.]” if the child
were returned to their care.
      A parent’s lack of insight into and denial of dependency issues support
a finding that the parent is not likely to modify behavior without court
supervision. (In re A.F. (2016) 3 Cal.App.5th 283, 293 [“In light of mother’s
failure to recognize the risks to which she was exposing the minor, there was
no reason to believe the conditions would not persist should the minor remain
in her home.”]; In re Gabriel K. (2012) 203 Cal.App.4th 188, 197 [“[o]ne
cannot correct a problem one fails to acknowledge”]; In re Esmeralda
B. (1992) 11 Cal.App.4th 1036, 1044 [“denial is a factor often relevant to
determining whether persons are likely to modify their behavior in the future
without court supervision”].)
      When considering Mother’s request for unsupervised visits, the court
stated it did not “[discount] the facts of the case,” but believed Mother had
earned the opportunity to “do some parenting” with D.W. The court wanted to
allow her to prove herself in a limited setting before returning him to her
care. The court said it would modify the order if there were problems with
the visits.

                                       26
      We may infer from the totality of the record that the court did not
believe there were reasonable means at the time of adjudication to safely
return D.W. to his parents until both he and the parents make additional
progress. (See In re John M. (2012) 212 Cal.App.4th 1117, 1127 [a juvenile
court could reasonably determine based on prior conduct that a child could
not be safely placed in a parent’s custody in the hope the parent would
comply with court orders or Agency supervision].)
      This case is starkly different from the other cases cited by Mother. The
case of In re Henry V. (2004) 119 Cal.App.4th 522 involved a single instance
where a child sustained unexplained burns on his bottom, apparently from a
curling iron. (Id. at p. 526.) The appellate court reversed a removal order
because the juvenile court did not make dispositional findings based on clear
and convincing evidence and did not consider allowing the completion of a
bonding study while the child was placed with the mother as a reasonable
alternative to removal. (Id. at pp. 529–530.) In re Ma. V. (2021) 64
Cal.App.5th 11 involved removal of mother’s children based on domestic
violence between mother and her then boyfriend. (Id. at p. 14.) By the time
of disposition hearing, however, months had passed since any domestic
violence episodes, mother had left the boyfriend, and she testified she was
completing voluntary services through the Veteran’s Administration. The
juvenile court agreed the issues that brought the children into detention had
aged out and that the mother had changed. However, the court removed the
children from mother’s care based on the “ ‘historical issue of domestic
violence’ ” and the lack of independent confirmation from the Veteran’s
Administration that mother was engaged in voluntary services. (Id. at pp.
20–21.) The appellate court reversed, concluding there was insufficient
evidence by a clear and convincing standard to remove the children and

                                      27
expressed concern about removing children based on “historical” evidence of
domestic violence. (Id. at p. 25–26.)
      In contrast, the Agency has been involved with this family for most of
D.W.’s life. He suffered years of severe neglect, both physically and
emotionally. Although the parents began to be more cooperative with
medical providers and showed some progress with their services shortly
before the adjudication and disposition hearing, there was substantial
evidence that D.W.’s removal from the parents was necessary for his
wellbeing until they make further progress with their services to show they

can protect and care for him.12

12     Even if we were to conclude that the court failed to make sufficient
factual findings for removal under section 361, subdivision (c), such a failure
can be either harmless or prejudicial error depending on the circumstances.
(In re Jason L. (1990) 222 Cal.App.3d 1206, 1218 [failure to make required
findings “will be deemed harmless where ‘it is not reasonably probable such
finding, if made, would have been in favor of continued parental custody’ ”].)
Under the circumstances presented here, we find it improbable that the
juvenile court would have made a different decision on the question of
D.W.’s removal even if it had recited additional factual findings. Therefore,
any error was harmless. (In re Celine R. (2003) 31 Cal.4th 45, 58, 60
[harmless error test applies in dependency matters].)

                                        28
                              DISPOSITION
     The order is affirmed.

                                            DATO, J.

WE CONCUR:

McCONNELL, P. J.

IRION, J.

                                  29