Filed 4/3/13 In re Viola B. CA5



                  NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions not certified for
publication or ordered published, except as specified by rule 8.1115(b). This opinion has not been certified for publication
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              IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                                       FIFTH APPELLATE DISTRICT
 
 


In re VIOLA B., Person Coming Under the
Juvenile Court Law.

KERN COUNTY DEPARTMENT OF HUMAN                                                            F065202
SERVICES,
                                                                               (Super. Ct. No. JD125374)
         Plaintiff and Respondent,

                   v.                                                                             
                                                                                         OPINION
A.G.,

         Defendant and Appellant.



         APPEAL from a judgment of the Superior Court of Kern County. Louie L. Vega,
Judge.
         Liana Serobian, under appointment by the Court of Appeal, for Defendant and
Appellant.
         Theresa A. Goldner, County Counsel, and Jennifer E. Feige, Deputy, for Plaintiff
and Respondent.
                                                        -ooOoo-
       A. G. (mother) appeals the disposition order removing the minor, Viola B., from
her custody under Welfare and Institutions Code section 361, subdivision (c)(1),1 and
denying reunification services under section 361.5, subdivision (b)(2). After concluding
the disposition order is supported by substantial evidence and it was not an abuse of
discretion to deny reunification services, we affirm the disposition order.
                   FACTUAL AND PROCEDURAL BACKGROUND
       The minor, who was born prematurely in June 2006, has spent a large part of her
young life hospitalized due to complex medical conditions, including cardiofacial-
cutaneous syndrome,2 chronic respiratory failure, seizure disorder, chronic lung disease,
mental retardation, cerebral palsy, and gastroesophageal reflux disease. She depends on a
tracheostomy and ventilator to breathe and a gastrostomy tube (G-tube) to receive
nutrition. Sadly, the minor’s genetic condition is non-recoverable; children with her
condition generally die young from respiratory infection or organ failure.
       In November 2010, the Kern County Department of Human Services (the
department) took the minor into protective custody. At the time, the minor was
hospitalized at Children’s Hospital Los Angeles (CHLA). Hospital staff reported that the
minor’s parents, mother and Jimmy B. (father), were interfering with the minor’s medical
care, including by loosening her tracheostomy ties (trach ties), which can be life
threatening. After she was discharged from CHLA, the minor was placed at All Saints



1      All further statutory references are to the Welfare and Institutions Code unless otherwise
indicated.
2       The record contains the following definition of this condition: “Cardiofacial-Cutaneous
(CFC) syndrome is a rare genetic condition that typically affects the heart (cardio-), facial
features (facio-) and skin (cutaneous). It is seen in equal frequency in males and females and
across all ethnic groups. Children with CFC syndrome may have certain features that suggest the
diagnosis, such as relatively large head size, down-slanting eyes, sparse eyebrows, curly hair,
areas of thickened or scaly skin, and small stature. Most will also have a heart defect.”


                                               2
Subacute Facility (All Saints) in Los Angeles and has resided there ever since. When
necessary, she is transferred to CHLA for treatment.
         The minor’s parents are both developmentally disabled. They have been
diagnosed with mild mental retardation and are considered high functioning. Mother also
has epilepsy and Sturge-Weber Syndrome.3 Father has a severe speech impediment. The
parents reside together in Bakersfield and visit the minor in Los Angeles on a regular
basis.
         Although the parents have demonstrated deep love and concern for the minor and
have been able to care for her at home for brief periods of time, they have a long history
of being uncooperative with medical care providers and resistant to following instructions
on how to provide adequate medical care for the minor. According to Susan McArthur, a
public health nurse who has worked with the family for an extended period of time, the
parents do not hesitate to take the minor to the hospital when necessary. But once the
minor is admitted, conflicts occur between the parents and hospital personnel. The
parents will not cooperate with medical professionals at the minor’s bedside, nor will
they take instruction from the physicians dictating her plan of care. The parents are
“adamant that they are the only ones who can really provide care for [the minor].”
         The parents’ behavior has resulted in a number of medical care providers declining
to work with the family, including Children’s Hospital of Central California (CHCC),
where the minor has spent substantial amounts of time since birth. CHCC has a special
clinic for children with complex medical problems like the minor. However, the minor


3      The record contains the following definition of the syndrome: “Sturge-Weber Syndrome
(encephalotrigeminal angiomatosis) is a congenital, non-familiar disorder of unknown incidence
and cause. It is characterized by a congenital facial birthmark and neurological abnormalities.
Other symptoms associated with Sturge-Weber can include eye and internal organ irregularities.
Each case of Sturge-Weber Syndrome is unique and exhibits the characterizing findings to
varying degrees.”


                                               3
will no longer be admitted to CHCC as a patient except on an emergency basis.
Dr. Horsepool, a CHCC doctor, reported that treating the minor entailed a “constant
battle” with the parents, who would do things their own way despite medical orders.
Dr. Horsepool noted the parents were inflexible in their thinking and had difficulty
following “changing directions.” They also had a “false belief” the minor would get
better. Dr. Horsepool believed a subacute facility was the best placement for the minor.
Based on his experience with the parents, he predicted that, if the minor were returned
home, the parents would continue to bring the minor to the hospital over and over again
and, when she eventually died, would blame whoever was caring for her at the time.
       Another health care provider that will no longer work with the parents is Maxim
Healthcare Services (Maxim), an agency in Bakersfield which provided in-home nursing
services to the minor between December 2006 and May 2007. Kathleen Schoen,
Maxim’s director of nursing, reported that the parents did not appear to understand the
extent of the minor’s medical problems but seemed to have “a stero[]typical view of baby
care.” The parents would disregard specific instructions from the minor’s primary
physician, including not to take the minor out in wet and cold weather due to her severe
respiratory problems. In addition, although the minor was prone to fevers, the parents
would set their thermostat at 75 to 80 degrees and bundle the minor in blankets and put
her in bed with them underneath their sheets and blankets. When the night nursing staff
would take her out of bed to cool off, “sure enough [the minor] would be running a
fever.” The parents would become very upset at the nursing staff about this and did not
seem to understand that their actions were causing the minor to have a fever.
       Schoen reported that Maxim finally discharged the family after a number of
incidents in which father lost his temper and made threatening movements towards
nursing staff. Schoen confirmed that her agency was no longer willing to serve the
family. However, they might consider it if father “was out of the home and not in the

                                            4
picture at all.” According to Schoen, although there were other nursing agencies in Kern
County, Maxim was the only agency that provided in-home pediatric nursing.
       On November 4, 2010, the department filed a dependency petition on the minor’s
behalf, alleging the minor had suffered, or there was a substantial risk she would suffer,
serious physical harm or illness as a result of her parents’ willful or negligent failure to
provide her with adequate medical treatment, and the parents’ inability to provide regular
care for her due to their developmental disabilities (§ 300, subd. (b)).
       According to the allegations in the petition, the minor was hospitalized at CHLA
in October 2010, where the medical staff instructed mother on the need for tightness of
the minor’s trach ties. Mother disregarded these instructions and loosened the minor’s
trach ties on four different occasions and argued with medical staff when they retightened
the trach ties. On October 23, 2010, mother loosened the minor’s trach ties to the point
the tube fell out, resulting in a respiratory problem and decline in the minor’s oxygen
saturation. Because mother’s interference with the minor’s medical care could
potentially result in her death, CHLA restricted mother to supervised visits. The petition
further alleged that father “became volatile and assaultive towards the hospital social
worker by ‘blocking’ her from leaving a room.” Both parents also threatened to take the
minor and leave against medical advice.
       On November 5, 2010, the juvenile court ordered the minor detained and set a
jurisdiction hearing. The parents were permitted supervised visits with the minor every
other week for two hours. The jurisdiction hearing was continued several times. In the
meantime, the department filed a detailed jurisdiction report, documenting the evidence
supporting the allegations in the dependency petition, and two supplemental reports,
documenting the parents’ continuing lack of cooperation with medical staff.
       On December 22, 2010, CHLA contacted the social worker and informed her that
the minor needed surgery to revise her G-tube because it was leaking, but mother was

                                              5
refusing to sign a consent form for the surgery. When the social worker followed up with
a phone call to mother, mother stated she would not consent to surgery until she could see
the minor. While they were talking, the social worker could hear father yelling in the
background. Mother expressed the opinion that All Saints had “messed up” the G-tube
and this was why the minor needed surgery. The social worker arranged for a supervised
visit so that mother could sign the consent form.
       After the surgery on December 23, 2010, Dr. Garcia, the minor’s main doctor at
CHLA, came in and told the parents the minor had done well and could be discharged to
All Saints in a few days. The doctor also talked about why the surgery was done. The
parents indicated they had no questions for the doctor at that time. However, after
Dr. Garcia left the room, mother criticized what had been done and said a different type
of tube should have been used. When the social worker asked mother why she did not
talk to the doctor about it, mother said she did not want to get in trouble by arguing with
the doctor.
       After the minor was released from CHLA and transferred back to All Saints on
January 3, 2011, mother refused to sign the admissions packet required by All Saints
based on her belief that the facility had caused the minor to become ill and require
surgery. The minor subsequently received additional treatments at CHLA. On
January 21, 2011, All Saints contacted the social worker and reported that it now had four
admissions packets the parents needed to sign, explaining the parents had to sign a new
admissions packet every time the minor was released from the hospital.
       On January 27, 2011, while the parents were attending a supervised visit with the
minor, All Saints’ vice president of operations informed the social worker that, unless the
parents signed the admissions packets, the facility would be forced to discharge the minor
that day. When the social worker and All Saints staff tried to explain the situation to the
parents, the parents continued to refuse to sign the paperwork and started raising their

                                             6
voices. The social worker then started calling the attorneys involved in the dependency
proceeding to apprise them of the situation. The same day, an ex parte hearing was held
and the juvenile court ordered the minor to remain at All Saints.
       Prior to the jurisdiction hearing, the juvenile court ordered the parents to undergo a
psychological evaluation by Dr. Allison Little to determine the necessity of appointing a
guardian ad litem for each parent. At a hearing on March 16, 2011, the court determined
each parent was in need of a guardian ad litem and made the necessary appointments.
       Following the contested jurisdiction hearing on March 22, 2011, the juvenile court
found all the counts and specific allegations in the dependency petition to be true. The
court set a disposition hearing and reappointed Dr. Little to evaluate the parents on the
question of whether they could benefit from reunification services. At the department’s
request, the juvenile court continued the disposition hearing again and appointed
Dr. Eugene Couture to evaluate the parents.
       After numerous continuances, the disposition hearing commenced over a year
after the jurisdiction hearing. In the interim, the department filed seven reports. The
original disposition report, prepared in late June 2011, recommended removing the minor
from the parents’ custody, adopting a permanent plan of long-term foster care, and
continuing the minor’s placement at All Saints. Based on the results of the two
psychological evaluations, the report also recommended denying reunification services to
the parents. Both Dr. Little and Dr. Couture concluded that the parents were incapable of
utilizing reunification services due to the parents’ developmental disabilities.
       Dr. Little evaluated the parents on March 29, 2011. She reported that, while
interviewing both parents, father would often raise his voice, stand up in a “threatening”
manner, and argue about the case. Although his arguments were largely unintelligible
due to his speech impediment, he clearly was angry and had difficulty controlling his



                                              7
emotions. During these episodes, mother frequently told father to “be quiet,” “shut up”
and “sit down.”
       During the evaluation, Dr. Little asked mother if she would allow outside agencies
to support her in the medical care of the minor. Mother said it would be okay, but she
would not want them to help the whole day. When Dr. Little asked mother what she
would do if she disagreed with recommendations from the minor’s primary care
physician and supportive medical staff, mother responded:

       “I know about my baby. They expected her to live only two years, but I got
       her to live four years. But now she’s fighting for her life in Los Angeles. I
       think she’s not happy with all this stuff that’s going on. They can’t take
       care of her. Probably not giving her the right medicine. They should
       already know the medicines. She’s dying slowly down there. It’s different
       down there. It was better before. She’s always asleep now to keep her
       calm. They can’t keep her calm when she’s awake.”
When Dr. Little attempted to pursue her last question further, mother “became somewhat
defensive and was unable or unwilling to discuss the issue further.”
       Dr. Little reported that mother obtained an IQ score of 69, which fell in the range
of mild mental retardation. When asked about psychotic symptoms, mother described
seeing and hearing ghosts at the hospital. Mother’s records also indicated that she
sometimes presented as suspicious to paranoid regarding others’ intentions. Based on
these factors, Dr. Little could not rule out a possible diagnosis of psychotic disorder, not
otherwise specified. However, she did not have enough information to offer the
diagnosis with certainty.
       Dr. Little concluded the parents were incapable of utilizing reunification services
based on their developmental disabilities, as well as their failure to understand and
cooperate with medical staff recommendations in the minor’s best interests. Dr. Little
observed:



                                              8
       “[The parents] have been afforded numerous educational opportunities in
       order to participate in the medical care of the minor. However, even with
       this education the parents continue to disregard medical staff
       recommendations, treatment plans, and pursue their own beliefs regarding
       the needed medical care of the minor, potentially endangering their
       daughter’s life. These episodes have not thwarted the opinion that they
       know best, even to the point that the mother has engaged in behaviors that
       placed the minor at threat of death, as well as both parents threatening to
       take the minor out of the hospital against medical advice. Based on the
       parents’ interactions with supportive staff in both the hospital setting as
       well as in-home supports, their behavior ha[s] led to agencies refusing to
       provide medical attention to the minor.”
       A similar conclusion was reached by Dr. Couture, who evaluated the parents on
May 23, 2011. He observed the parents were “clearly functioning in the range consistent
with Mild Mental Retardation.” He described mother as “very suspicious and very
perseverative” and explained “[p]erseverative behaviors are those behaviors which are
repetitive, where the individual is not able to learn from feedback.” Dr. Couture noted
that mother “does seem to get stuck on issues and has a great deal of difficulty in
changing,” indicating “she is not able to use outside information to make adequate,
independent decisions.”
       Based on his review of the records, Dr. Couture observed that, when the minor
“was younger and somewhat less involved,” the parents were able to learn some of the
skills necessary to maintain the minor in their home and provide care that was “adequate
for her complex medical situation.” However, Dr. Couture concluded,

              “I think the physicians, in this case, have come to the correct
       conclusion that the parents simply do not have the cognitive ability to
       understand what their daughter needs and when she needs it …. It is not
       acceptable to argue with the nursing staff. It is not acceptable to refuse
       services because you are suspicious. They must cooperate with the process
       of medical care and medical administration in order for their daughter’s
       care to be complete. I think, given their overall situation, they present an
       unacceptable level of risk to [the minor].



                                             9
               “This is a sad situation. It is my opinion that these parents could be
       good parents for a child without all of these extreme medical demands
       presented by [the minor]. However, in this situation, the demands are
       simply too high for them to cope. They have had repeated opportunities to
       learn to do better and they have not done so. It is, therefore, my opinion
       that they are mentally retarded and that this mental disability renders both
       parents incapable of utilizing family reunification services in this case.”
       During the year leading up to the disposition hearing, the parents complied with
their initial case plans by completing parenting and neglect classes. After initially
resisting, father also enrolled in and completed a recommended anger management
program.
       Supplemental reports filed near the time of the disposition hearing reflected that
mother continued to express disagreement with the opinions of medical professionals
regarding the minor’s care and father continued to have angry outbursts.
       During a supervised visit on February 9, 2012, the minor had three seizures, but
mother did not believe the first two were seizures despite being so informed by the nurse.
The social worker observed that, during the first seizure, the minor’s body began to
stiffen, she turned red to the point of almost looking purple, and her eyes moved rapidly.
The nurse administered medication rectally at five minutes. Within a few minutes, the
minor began to loosen up and her color began to look better. Mother whispered to the
social worker that it was not a seizure but a “breathing fit.” When the social worker
pointed out that the nurse had called it a seizure, mother repeated it was not a seizure and
said that giving the minor medicine would make her become immune to it as it was not a
seizure. The nurse then informed mother that the doctor had called it a seizure. The
social worker told mother that if the doctor called it a seizure, it was a seizure. Mother
whispered to the social worker that the minor also had “tantrums” and they looked just
like seizures.
       A little while later during the same visit, the minor had a second seizure. No
medicine was administered because the seizure did not last long. Mother told the social

                                             10
worker that the minor had a “tantrum” not a seizure. Approximately 15 minutes later, the
minor stiffened up, became red, and her eyes started moving rapidly. This time, mother
said the minor was having a seizure and the social worker called the nurse. The social
worker pointed out to mother that the minor did the same thing all three times. Mother
replied that she could tell the difference between a “tantrum,” a “breathing fit,” and a
seizure.
       On March 22, 2012, All Saints informed the social worker that the minor was
having difficulty breathing and was being transferred to CHLA that day. On March 29,
2012, the social worker informed the parents that the minor needed surgery to replace her
G-tube with a gastrojejunostomy tube (J-tube or GJ-tube). The parents were unwilling to
consent to the surgery and mother expressed the belief that removal of the G-tube would
kill the minor. When the social worker asked mother where she got that information,
mother stated that one of the hospitals had told her, but she could not remember which
one.
       On March 30, 2012, Edward Rivera, a CHLA social worker, spoke with the
parents regarding the medical team’s surgical recommendation to change the minor’s G-
tube to a GJ-tube. Rivera reported that after he explained the procedure, the pros and
cons, and that it would benefit the minor, mother was unable to reiterate what he had told
her.
       On April 2, 2012, mother called the department social worker and asked if she
could skip the next scheduled visit with the minor, who was then hospitalized at CHLA.
Mother explained she did not want to be there because she had an argument with the
CHLA social worker. The department social worker encouraged mother to visit the
minor and said she would call the hospital and request that only she and the parents be
present during the visit. Mother stated she objected to the surgery and wanted to help the
minor by not making her go through another surgery. Mother explained she had been

                                             11
told that the minor’s current G-tube would last a long time, and she felt that the hospital
wanted to argue with her. The social worker told mother the doctors were just trying to
explain why the surgery was needed. Mother replied that it was not needed and she did
not want to argue.
       On April 5, 2012, the social worker met with the parents and Dr. Elizabeth
LaGuardia, one of the pulmonologists who had been treating the minor at CHLA. The
social worker told Dr. LaGuardia that the parents were now willing to sign the consent
forms for the GJ-tube surgery. When the doctor asked whether the parents had any
questions, mother hesitated and then said, “not really.” The social worker told
Dr. LaGuardia that mother had voiced concerns and that another hospital had told her that
removal of the G-tube would hurt the minor. Dr. LaGuardia explained to the parents that,
during the procedure, they would use the same area but would put a tube a little farther in
the stomach into the beginning of the intestine to help the minor with reflux, aspiration,
and lung infections. Although there were risks with any surgery, the procedure could
help improve the minor’s health and lead to fewer illnesses.
       After Dr. La Guardia explained the surgery, mother said her attorney advised her
to sign the consent form or else it would look bad on the parents and the minor would not
be returned to them. The social worker asked mother if she would consent to the surgery
even if the minor was not in protective custody. Mother said that she would. When
asked if she understood what the surgery was for, mother said she did but was concerned.
       During the parents’ conversation with the social worker on April 5, 2012, father
became upset and complained about his attorney. Father said that if the minor was not
returned to them at court, he was going to “hit the social workers” and “attorneys.”
Because of his speech impediment it was difficult to understand what he was saying, but
the social worker heard him say something with the word “dead” in it. While father was
making these statements, mother told him to “shut up.”

                                             12
       Father became agitated again during a supervised visit at All Saints on April 19,
2012. When the parents arrived, mother became very concerned and informed the staff
she was scared because the minor was turning blue. They came in to check on the minor
but could not find anything wrong. Father began to get upset and yelled, “you are not
doing anything for my baby. She is dying and turning blue.” Mother asked the staff to
suction the minor’s trach and they did. When a staff member went to throw the mucous
away, father grabbed it and placed it in his pocket. The staff member pulled the social
worker aside and said he was afraid father was going to hit him because father had
thrown chairs in the past.
       The parents were then taken into a separate room to meet with several
representatives of All Saints, including the vice president of operations. The vice
president of operations told the parents their behavior was unacceptable and, if they acted
out again, the facility would seek a restraining order to prevent them from visiting the
minor. After the meeting, the rest of the visit went better. The parents calmed down and
were compliant. However, the vice president of operations told the social worker that she
was concerned about the possibility the minor would be returned to the parents. Based on
her observations, she did not feel the parents had the ability to maintain a quality level of
care for the minor.
       After conducting updated psychological evaluations of the parents on April 24,
2012, Dr. Little reported that it continued to be her professional opinion that the parents
were unable to utilize reunification services. Dr. Little noted that “even with education
offered by the medical treatment team, the mother has continued to demonstrate her own
opinion as it relates to the medical best interest of her daughter.” Dr. Little observed that
the parents continued to express the belief that the surgery to replace the minor’s G-tube
was not necessary, although they had consented on the advice of their attorney. Dr. Little
also cited the incident where mother persisted in the belief that the minor was not having

                                             13
seizures despite medical advice to the contrary. Dr. Little opined “[t]his incident reflects
mother’s inability to recognize the severity of their daughter’s fragile health and
symptoms associated with her medical diagnoses.” Dr. Little concluded that “once again
it is my opinion that the mother and [father] are incapable of utilizing reunification
services at this time based upon their developmental disability, as well as failure to
understand and cooperate with medical staff recommendations in the best interest of their
minor daughter.”
       The contested disposition hearing finally commenced on May 30, 2012. After the
court heard testimony on May 30, there was another delay and the hearing finally
resumed on June 20 and concluded on June 22, 2012.
       On the first day of the hearing, a letter prepared by Dr. LaGuardia was introduced
and the parties stipulated it would be admitted in lieu of testimony. The letter presented a
brief overview of the minimum requirements to care for the minor at home, including,
among others things, a “[h]ome skilled nursing agency with experience/ability to care for
pediatric patients on home mechanical ventilation (24 hours/day of home skilled nursing
care is recommended).”
       Mother also called Dr. Christine Deeths as an expert witness. Dr. Deeths, a family
medical doctor in Bakersfield, testified she had experience working with children with
severe medical issues and helped coordinate their care with multiple specialists.
Dr. Deeths examined the minor at All Saints and opined the minor could be maintained at
home if all the proper services were put into place. The doctor also met with the parents
and talked to them about the minor’s condition. She found they both understood the
minor’s condition and were able to articulate “knowledge of the fundamental care to
maintain the child’s needs to survive, the ventilator, the tracheostomy and the G-tube.”
       Dr. Deeths testified that the minor’s medical records reflected that the minor, who
was then almost six years old, had originally been expected to live only between two and

                                             14
two and a half years of age. The records also reflected that, on more than one occasion,
the parents had successfully completed training at CHCC and had been able to care for
the minor for periods of 24 to 48 hours without any concerns. According to Dr. Deeths,
the protocols the parents had to meet for the minor to be discharged from CHCC were the
same as the requirements set forth in Dr. LaGuardia’s letter.
       Dr. Deeths testified she was familiar with the resources available in Bakersfield
and opined that there was nothing being done for the minor at All Saints that could not be
done for her locally. Dr. Deeths also described some of the negative impressions she had
formed of All Saints during the 20 to 30 minutes she spent with the minor. She also
testified generally about the benefits of living in a home setting versus a hospital setting.
       Dr. Deeths was later recalled and testified that, based on a conversation she had
with Dr. LaGuardia, she did not interpret Dr. LaGuardia’s letter to mean that “there needs
to be a nurse in the home 24 hours a day, seven days a week.” Rather, Dr. Deeths
understood it “to mean that there needs to be an availability of a nurse by telephone in the
event of a problem or emergency 24 hours a day.”
       Dr. Deeths acknowledged that in Bakersfield, Maxim was the only company that
provided in-home skilled nursing to pediatric patients, but she believed there were other
ways that need could be met, including using a nursing agency from another city or
utilizing the services of private nurses. The minor might also be eligible for home
hospice care, as new legislation had recently been passed allowing pediatric patients
already on home ventilators to continue to use ventilators even when under hospice care.
       Mother also called a number of witnesses who provided positive testimony
regarding the parents’ ability to care for the minor at home. Carolyn Tellanian, a clinical
social worker at CHCC, testified that she had known the parents for approximately three
years and thought they “did an exceptional job” caring for the minor. Tellanian
explained that, before the parents were allowed to take the minor home from the hospital,

                                             15
they each had to provide 48-hour care for the minor with the nurses standing by to
provide help if needed. When the nurses and respiratory therapist signed off to allow the
parents to take the minor home, it meant they were very confident with the parents’ care
of the minor.
       Tellanian confirmed that currently the minor could only be admitted to CHCC in
the case of an emergency and could not be a regular patient at the clinic. Although father
tended to raise his voice when he was excited and had made the nurses uncomfortable,
Tellanian never thought he was a physical threat to anyone. She observed the parents
were very attentive and affectionate towards the minor. It never appeared to her that their
disabilities prevented them from learning how to care for her. Rather, Tellanian thought
the parents “learned everything … exceptionally well.” Father had an “impressive”
understanding of the medical equipment and the parents “worked as a team very well.”
       Danny Lack, a respiratory therapist, testified he worked for a company that
provided ventilators for in-home use. His primary responsibilities included training
families on how to care for patients and manage their equipment. When Lack met the
parents in November 2011, they were able to articulate most of the settings on a
ventilator they had used with the minor a year earlier. He was “surprised by the amount
of information that they retained.” Despite the parents’ developmental disabilities, Lack
felt he would be able to train them how to use the two types of ventilators currently used
in home-care settings.
       During his meeting with the parents, Lack brought trach ties and a tube similar to
the ones they would use on the minor and asked them to place them on one another. The
parents demonstrated they could properly attach the trach ties. Lack also brought in a
ventilator and showed the parents how to use it. After speaking about other topics for a
while, Lack asked the parents to demonstrate what he had taught them about the
ventilator. The parents retained the information and repeated it to him.

                                            16
       On cross-examination, Lack testified that his agency did not provide in-home
nursing, but he had worked with three pediatric in-home agencies in Bakersfield,
including Maxim, Around the Clock, and Interim.
       Mother also called Dr. Little, who confirmed that it was not her opinion “the
parents were incapable of learning anything.” However, Dr. Little testified, “I feel like
collectively, with their development disability, their unwillingness at times to follow
medical directives, their behaviors together make them, in my opinion, not able to utilize
family reunification services at this time.” Dr. Little observed that despite completing the
components of their case plans, the parents’ behavior since was such that it was still her
opinion they were not capable of benefiting from reunification services. Although she
thought the parents could participate in and benefit from classes, it appeared they were
unwilling to change their behavior.
       In her testimony, department social worker, Dina Tucker, acknowledged that,
although mother was argumentative with medical staff, she had not done anything to
interfere with the medical equipment or treatment of the minor for the past year and a
half. Mother was also capable of putting the trach tube back in and was actually the one
who put it back in on the occasion at issue when it fell out because mother loosened the
trach ties.
       Tucker further testified that the parents had consistently visited the minor until
recently. The parents’ explanation for why they had not attended recent visits with the
minor was that there were always concerns at the visits and they did not want to argue
with the staff and upset the minor.
       Tucker was concerned the parents were not going to be able to get the supportive
services they needed based upon their history of noncompliance with doctors and nursing
agencies. When she researched providers of in-home nursing services, the only two
providers she found were Maxim and Interim; Around the Clock did not come up.

                                             17
Interim did not provide pediatric nursing services and Maxim was not willing to take the
minor unless the father was out of the house. The department was unable to locate a
subacute facility in Kern County where the minor could be closer to the parents.
Although there was one in Delano, it was not available.
       Department social worker, Colleen Saenz, testified that the parents had been
offered a choice to visit the minor once a week for an hour, or every other week for two
hours. They chose the latter because it was too expensive to drive down to Los Angeles
every week. Without traffic, the trip took about an hour and 40 minutes. During visits,
the parents showed appropriate concern towards the minor and were affectionate with
her.
       When the parents were not at All Saints, someone spent a minimum of two to
three hours with the minor each day. There was a teacher who came in and did things
like talk and sing to her. Someone also picked her up each day. Saenz never observed
the minor react differently to the parents than to anyone else. The minor had a positive
response to touch and both the parents and the nurses were able to calm her down by
rubbing her hair.
       Saenz, who was present during the incident when mother expressed the opinion
that the minor was not having seizures, confirmed that mother did not try to interfere with
what the medical staff was doing but just whispered her opinions in the social worker’s
ear.
       With respect to the parents’ initial resistance to surgery to replace the minor’s G-
tube with a GJ-tube, Saenz testified that they expressed a legitimate concern based on
their report of a previous experience in which the minor had an infection following a
surgery. Saenz’s understanding was that the new surgery would help the minor from
getting ill so often. Because of the minor’s chronic lung disease, she was always having
infections and the placement of a GJ-tube would alleviate some of the mucous and

                                             18
aspirations that were getting down into her lungs. Saenz testified the parents remained
“on the fence” about the surgery but consented after being advised to do so by mother’s
attorney.
       Saenz further testified she had investigated other out-of-home care options for the
minor, including the possibility of placing her with a foster family living closer to the
parents. However, the fee for a foster family was between $6,000 and $9,000 per month,
which was not covered under Medi-Cal or Social Security, and the parents said they
could not afford that. Other than the unavailable facility in Delano, there was a subacute
facility in Lancaster, but Saenz had heard from people at CHLA and All Saints that it was
not a good facility.
       Mother and the minor’s maternal grandfather also presented testimony describing
positively the care routines the parents followed in the past when caring for the minor at
home, as well as their appropriate responses in emergency situations.
       After listening to the arguments of counsel, the juvenile court ruled, in relevant
part, as follows:

              “The two medical experts or psychological experts in this case,
       Doctors Little and Couture, have both concluded that the parents are not
       capable—or incapable of utilizing reunification services based on their
       developmental disability as well as their failure to understand and cooperate
       with medical staff recommendations in the best interests of their daughter.
       That’s, in essence, what they have concluded.

              “The evidence presented to this court regarding this child’s
       prognosis was that apparently at the outset, it was estimated—or the
       prognosis was that she might survive to two and a half years of age. And
       now a week and a day from today, she’ll be turning six years old. So,
       certainly, those types of educated conclusions aren’t always predictive.
       Certainly, they are what we have to rely on to the extent that they can be
       used for making plans.

               “What I’ve read in these reports and was testified to as well is that
       the parents’ behavior at the children’s hospital in Madera .… [] …was such
       that they could only utilize their services on an emergency basis.
                                             19
Children’s Hospital Los Angeles has similar concerns. A local provider of
services ceased providing those services because of the behavior of at least
one of the parents, [father]. And the indication from the testimony given by
Mr. Lack was that [if father] were not in the home, his understanding was
that they might provide those services.

        “That is consistent with what the—what we’ve heard as far as—and
reviewed as far as the evidence is concerned regarding these parents’ ability
to benefit from reunification services—or to be able to utilize those services
is the better way of putting it.

       “There is a schism between the parents and those they have to rely
on for providing services for their child. Most recently, according to the
mother’s testimony, this has resulted in them not visiting this child. I can’t
say that the evidence from Doctors Little and Couture is not competent
evidence, that the parents are unlikely to be able to adequately care for this
child. I believe the parents should still be able to have an ongoing
relationship with this child. But the court cannot agree with counsel’s
argument that family maintenance services should be provided and that
reunification services should be extended .… [¶]

      “I think there is clear and convincing evidence at this point that
supports the recommendations that have been proffered by the Department
of Human Services, and the court is going to follow those
recommendations. [¶] … [¶]

       “The court has read and considered the social worker’s reports and
supplemental reports …, as well as the other evidence presented during
these past four hearing dates, and makes the following findings and orders
based on that information: [¶] … [¶]

        “There is clear and convincing evidence that there is a substantial
danger to the physical health, safety, protection or physical or emotional
well-being of the child or there would be if the physical custody of the child
is not removed from the parents or guardians, and there are no reasonable
means to protect the child’s physical health without removal of the child
from the physical custody of the parents .… [¶] … [¶]

       “Family reunification services are not to be provided to the parents
… as there is clear and convincing evidence the child comes within Section
361.5 subdivision (b)(2) of the Welfare & Institutions Code.



                                      20
              “The aforesaid are suffering a mental disability as described in
       Chapter 2 commencing with Section 2820 of Part 4, Division 12 of the
       Family Code which renders the aforesaid incapable of utilizing services and
       competent evidence from mental health professionals that establishes that
       even with services, aforesaid are unlikely to be capable of adequately
       caring for the child within twelve months.”
                                       DISCUSSION
I.     Substantial evidence supports the disposition order.
       A child may properly be removed from the physical custody of her parents if the
court determines, based upon 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 parents’ … physical custody.” (§ 361, subd. (c)(1).) However, even
when the standard of proof below is clear and convincing, we cannot weigh the evidence
on appeal. We must uphold the juvenile court’s order if there is substantial evidence to
support it. (In re Basilio T. (1992) 4 Cal.App.4th 155, 170.)
       The substantial evidence test is well known: “In juvenile cases, as in other areas
of the law, the power of an appellate court asked to assess the sufficiency of the evidence
begins and ends with a determination as to whether or not there is any substantial
evidence, whether or not contradicted, which will support the conclusion of the trier of
fact. All conflicts must be resolved in favor of the respondent and all legitimate
inferences indulged in to uphold the verdict, if possible. Where there is more than one
inference which can reasonably be deduced from the facts, the appellate court is without
power to substitute its deductions for those of the trier of fact.” (In re Katrina C. (1988)
201 Cal.App.3d 540, 547.)
       Before addressing mother’s sufficiency of the evidence challenge, we briefly
address her claim that the juvenile court failed to state a factual basis for its section 361,


                                              21
subdivision (c)(1) findings but instead “focused exclusively” on the department’s
recommendation to deny reunification services under 361.2, subdivision (b)(2), based on
the psychological evaluations, which concluded the parents were unable to utilize
reunification services. The record belies mother’s claim. In addition to the psychological
evaluations, the court specifically referred to testimony presented at the disposition
hearing and information contained in the reports, which supported the court’s finding of
“a schism between the parents and those they have to rely on for providing services for
their child” and the court’s conclusion that “the parents are unlikely to be able to
adequately care for this child.”
       Although the juvenile court did appear to rely heavily on the psychologists’
evaluations in ordering the minor removed from mother’s custody, this was not improper.
The experts did not limit their opinions to the question of the parents’ ability to utilize
reunification services but also addressed the parents’ ability to provide adequate care for
the minor and cooperate with medical staff in the minor’s best in the minor’s best
interests.
       Mother’s reliance on Tracy J. v. Superior Court (2012) 202 Cal.App.4th 1415
(Tracy J.) is misplaced. That case teaches that,

       “‘Harm to the child cannot be presumed from the mere fact of [the
       developmental disability] of the parent .… The proper basis for a ruling is
       expert testimony giving specific examples of the manner in which the
       mother’s behavior has and will adversely affect the child or jeopardize the
       child’s safety.’ [Citation.]” (Tracy J., supra, at p. 1424, italics added.)
Here, the psychologists submitted detailed reports with specific examples of how
mother’s past and current behaviors placed the minor’s health and safety at risk. There is
no indication either expert presumed harm to the minor based on the mere fact of
mother’s developmental disability or that the juvenile court ever adopted such a position.




                                              22
          We likewise see no support in the record for mother’s claim that the court violated
her equal protection rights by basing its removal order solely on her mild mental
retardation instead of considering the relevant factors under section 361, subdivision
(c)(1).
          Focusing on the evidence favorable to her, mother argues the disposition order
removing the minor from her custody is not supported by substantial evidence. She
argues the minor could be properly protected if returned to the parents’ home under court
supervision. Her argument assumes she and father would be able to obtain all the
services necessary to maintain the minor safely at home. She does not acknowledge the
parents’ history of being dropped by medical caregivers and facilities due to behaviors
the parents continued to exhibit up to the time of the disposition hearing, including
frequently disagreeing with the opinions of the doctors and nurses charged with the
minor’s care. Thus, even assuming the parents were able to find agencies willing to work
with them, the record supports the inference that a conflict or schism between the parents
and medical care providers would almost certainly arise again, jeopardizing the minor’s
health and safety.
          Evidence of mother’s persistence in expressing inaccurate and inflexible opinions
regarding the minor’s condition and medical needs indicates mother cannot presently be
trusted to follow medical advice. Just a few months before the disposition hearing,
mother stubbornly insisted that two seizures suffered by the minor were not seizures but
merely “a breathing fit” and a “tantrum.” Mother would not alter her opinion when
confronted with the contrary opinion of the physician and the fact the minor’s symptoms
were identical to the ones the minor presented during an event mother acknowledged was
a seizure. Mother also expressed a troubling belief that the medication the nurse
administered to control the first seizure was unnecessary and would result in the minor
becoming immune to it. Although mother testified at the disposition hearing that she

                                               23
would have administered the medication to the minor if the event had occurred while she
was caring for the minor at home, the record contains ample evidence from which the
court could reasonably infer mother was simply saying what she thought the court wanted
to hear and would follow her own beliefs if given the chance.
       Based on the record before us, we agree with Dr. Couture’s opinion that mother
presents an “unacceptable level of risk” to the health and safety of the minor and
conclude that substantial evidence supports the juvenile court’s disposition order
removing the minor from her care.
II.    The denial of reunification services was not an abuse of discretion.
       The juvenile court denied the parents reunification services pursuant to section
361.5, subdivision (b)(2), which provides: “Reunification services need not be provided
to a parent … when the court finds, by clear and convincing evidence .… [¶] … [¶] That
the parent … is suffering from a mental disability … and that renders him or her
incapable of utilizing those services.” We review the denial of reunification services for
abuse of discretion. (In re Nada R. (2001) 89 Cal.App.4th 1166, 1179.)
       No abuse of discretion appears. The original psychological evaluations and the
updated evaluation conducted shortly before the disposition hearing consistently
concluded that mother was suffering from a developmental disability and that her
developmental disability rendered her incapable of utilizing reunification services. Those
conclusions were well founded. As just discussed, throughout the proceedings, mother
persisted in her beliefs about the minor’s complex medical conditions, even when those
beliefs conflicted with those of the experienced medical professionals caring for the
minor. Thus, mother continued to exhibit the perseverative behavior Dr. Couture
originally observed, indicating her inability “to use outside information to make
adequate, independent decisions.” Dr. Little’s updated evaluation also observed that,
despite mother’s participation in parenting and neglect classes and efforts by medical

                                            24
staff to educate her, mother “continued to demonstrate her own opinion as it relates to the
medical best interest of her daughter.” In support of her opinion, Dr. Little cited recent
incidents, including the incident when mother insisted the minor was not having seizures
despite medical advice to the contrary. The psychologist observed that this incident
reflected “mother’s inability to recognize the severity of their daughter’s fragile health
and symptoms associated with her medical diagnoses.” Again, mother’s reliance on
Tracy J. is misplaced because the psychologists’ opinions here were well supported with
specific examples of behaviors demonstrating mother’s inability to utilize reunification
services. The court properly denied reunification services.
                                      DISPOSITION
       The disposition order is affirmed.



                                                                 _____________________
                                                                              HILL, P. J.
WE CONCUR:


 _____________________
WISEMAN, J.


 _____________________
PEÑA, J.




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