The Rhode Island Office of the Child Advocate has concluded through an extensive report released Tuesday that the Rhode Island Department of Child Youth and Families (DCYF) “created” the situation that led to the death of a 9-year-old Oakland Beach girl in January.

The child, Zah-Nae Rothgeb, was one of eight children under the supervision of one woman, Michele Rothgeb, who over the course of 13 years had contact with 13 different children in the foster care system through DCYF. Zah-Nae was diagnosed with Cerebral Palsy and had a slew of other health complications, and each of the children under Rothgeb’s care had at least one physical or mental health diagnosis.

“Over the course of 13 years, [DCYF] had multiple opportunities to intervene,” the report concludes. “Through complaints from the community, observations from their own employees and by concerns relayed by service providers, there were numerous opportunities to intervene and to prevent the death of this child. There will never be a realistic answer to the question of how can one person care for eight special needs children. It is our opinion that DCYF needs to be held responsible and accountable. Certain employees of DCYF showed poor judgment and disregard for the safety of the children in this home. We maintain that the actions, or inactions of DCYF staff contributed to the death of this child.”

Rothgeb is currently awaiting trial in Superior Court for charges of manslaughter and neglect/abuse of a child. The manslaughter charge carries a maximum sentence of 30 years in prison.

An extensive history revealed

The 57-page report examined internal records from DCYF and goes into great depth chronicling the entire history of Rothgeb’s involvement with DCYF, beginning with her application to become the legal guardian to her two grandsons in 2007.

This application was initially denied due to Rothgeb’s criminal background history, which included charges of possession of a controlled substance in 1982 in Indiana (for which she received a suspended sentence), possessing stolen goods in 1983 in Indiana (for which she served a year in prison) and larceny in 1993 in Florida for which she received probation. However, Rothgeb appealed the denial and was successful in that appeal, gaining guardianship of the two children.

In 2011, Rothgeb then first applies to become a foster parent, stating according to records, “I have ‘extra’ to share - extra love, extra space, extra time...just ready to do this.” This application, too, was initially denied due to the criminal background check. But once again, Rothgeb successfully appealed due to, in part, reference letters of support from her daughter and mother.

“The references submitted were from family members that [Rothgeb] had not seen or lived with for many years,” the Child Advocate report states.

After gaining approval, Rothgeb underwent pre-foster parent training in May of 2011, and on July 27, 2011 she was given foster parentship of Zah-Nae, who is referred to as Child “A” in the report. At the time, Zah-Nae was just two years old, and was "noted to be dependent in all areas of daily living," and had a range of medical complications from hydrocephalus, congenital aqueductal stenosis, Failure to Thrive (FTT) and moderate umbilical hernia.

The report catalogues a consistent struggle within the next six months for Zah-Nae to maintain a healthy weight, and the child may be in need of a feeding tube. Two days after the report that revealed her issues keeping Zah-Nae adequately fed, Rothgeb received her second foster child on January 5, 2012 – a 3-month-old who was diagnosed with Gastroesophageal reflux disease.

One day later, DCYF reported doubts that Rothgeb could adequately care for Zah-Nae, who she was now leaving in a high chair "all day long to feed her," per the report, and that, "Practically and developmentally this is not a good plan.” In April of 2012, the biological parent to the second fostered child likewise expressed doubts about Rothgeb being able to care for both children in addition to her two grandchildren. On Sept. 7, 2012 Rothgeb received her third foster child, a three-day-old infant.

Zah-Nae is reported to have started experiencing seizures in November of 2012, and had more in December. Responding to one of these incidents, EMS personnel found Zah-Nae "on the floor naked and cold," to which Rothgeb said she had placed the child on the floor after she noticed her having a seizure while trying to feed her in a high chair.

Also in December, the mother of Rothgeb’s second foster child reached out with concerns that the child was not receiving proper attention and was being harmed in the care of Rothgeb. DCYF reports from February, March, April and May all note the child was sitting in a high chair at the time of visits and only wearing a diaper. The child was later diagnosed with motor skill issues and cognitive delays.

In January of 2013, Rothgeb had to be instructed not to lay Zah-Nae on her back in an attempt to get her to swallow solid foods, as this could cause the child to asphyxiate. In April of 2013, Rothgeb became upset when a social worker did not confirm a visit before showing up.

In August of 2013, Rothgeb was caught trying to sell 10 cases of Zah-Nae’s specialty, prescription-only formula on Craigslist. She denied knowing the formula could not be given to other children without prescription and that the incident “was all a misunderstanding” and that the formula “was about to expire and she did not want it to go to waste.” Rothgeb was warned that she could face federal charges for such an action.

By September 13, 2013 Rothgeb had seven children in the home. However one of these children was removed from the home after they had disclosed to school personnel that they were “being locked in a room by [Rothgeb].” The report indicates, “There was no follow up by DCYF regarding the allegations…”

Unannounced visit

In November of 2013, a social worker made an unannounced visit to the home and it was apparent that “[Rothgeb] did not want [the social worker] in the home and this was evidenced by [Rothgeb] only opening the door a crack...verbalized wishing she had more notice as the house was not as clean as she would like." The social worker observed the has as having “clutter” but was not “unclean.”

As of July 2014, Rothgeb had eight minor children living in her home, including her two grandsons, one former foster child that she had adopted, four foster children and a child she was watching as a respite to another foster parent. It is also during this month that Zan-Nae had another seizure, this one lasting more than five minutes. However, due to the high number of kids in her care, Rothgeb stated she was unable to accompany Zah-Nae to the hospital.

In October of 2014, a Child Protective Services worker concluded, “I definitely think the number of children is a safety concern given she doesn’t have a lot of support,” but according to the Child Advocate report, "Other assigned workers did not share the concerns brought forward by the CPI and all children remained in the home. No additional supports or services were provided by DCYF for FM or the children.”

In April of 2015, Rothgeb received another infant, bringing the total children under six years old in her care to five and three children under two years old. It is during this time Rothgeb started the adoption process for Zah-Nae, which the Child Advocate report indicates was crucially flawed.

History not documented

“[Rothgeb]’s full history was not documented in this home study nor was there detailed information pertaining to each child living in the home,” it states. “[Zah-Nae]’s medical history was missing vital information in the report and failed to provide an accurate depiction of the significant needs of [Zah-Nae].” Regardless, Rothgeb successfully became the adoptive mother to Zah-Nae.

In June of 2015 the DCYF social worker for Zah-Nae engaged in an email conversation with Rothgeb delving into concerns they had received regarding reports of hoarding. “I feel bad...you know I love my girl to the moon, right? I don’t want you to feel she isn’t in good hands,” Rothgeb said in the email chain, to which the DCYF worker responded, “You need some RELAX pills. Your[sic] not the worst hoarder LOL. I am not worried.” The report indicates there was no further correspondence on this issue. 

In February of 2016 Rothgeb purchased the Oakland Beach home where Zah-Nae would eventually perish. At the time, she was fostering one child, had adopted four (including Zah-Nae) and still maintained legal guardianship of her two grandsons.

In June of 2016, the biological mother to one of Rothgeb’s adopted children gave birth to another baby, and Rothgeb requested a variance to allow her to bring in an additional foster – which would also bring her up to the maximum allowable number of children by a single parent, at eight. The report states that there were “concerns” about Rothgeb’s ability to care for an additional infant, but that she had the backing of the assigned social worker and supervisor, and the baby was placed in the home.

Rothgeb taken at her word

At this time, Rothgeb assured DCYF personnel that there were community support services in place should she need to utilize them for help and there was a friend and neighbor who came by often to assist her as well, but once again DCYF failed to follow up on this claim and took Rothgeb at her word.

“DCYF did not verify any of the supports [Rothgeb] identified nor did they run any clearances to determine if they would be appropriate caretakers with no disqualifying information preventing them from helping with the children and placed the infant in the home,” the report states.

In November of 2017, the DCYF licensing unit documented a re-licensing process that took place in August of 2017, which concluded all children under Rothgeb’s care were happy and in good condition. However, according to the report, “there was no follow up from DCYF to verify any of the information gathered during this visit. There was no follow up to determine if [Rothgeb] had the ability and supports in place to deal with all the documented medical, psychiatric and behavioral issues of all the children living in the home.”

Then, in January of 2018, a call was placed to the Child Abuse Hotline from a concerned community member who stated Rothgeb was “overwhelmed” and was often leaving the children in the care of her teenaged, eldest grandson who was described as having a high-functioning form of autism, and was incapable of properly caring for the other six kids in the house, in addition to his younger sibling.

Upon a subsequent investigation by Child Protective Services, Rothgeb initially refused to let the investigator enter the home. Once she relented, the investigator noted that, “The home was observed to be cluttered and out of order, there was a strong order of urine present. [Rothgeb] refused to allow CPI access to the 2nd floor bedroom area, rather instructed oldest grandson to carry the children one by one downstairs.”

The investigation resulted in findings of neglect against Rothgeb, however the Child Advocate report found that “There is no documentation that the Licensing Department conducted a home visit to follow up on the regulatory issues of this foster home.”

The last documented in-home visit by a social worker was in April of 2018. Rothgeb adopted her final foster child in July of 2018, after which there was no contact between Rothgeb and DCYF until the tragic incident of January 3, 2019, the gruesome details of which the Beacon has covered extensively.

DCYF blame spread across all levels

The Child Advocate’s report reprimanded DCYF across multiple areas, including failing to follow up on troubling behavioral issues with Rothgeb – including multiple instances of her having outbursts towards DCYF personnel and in front of social workers – a failure to adequately follow their own licensing procedures and a failure to follow up on concerns raised by Child Protective Services personnel and members of the community.

“There was faulty understanding of the role and responsibility of all DCYF staff in this case ensuring the safety and well-being of the children in this home. The record reflects the Licensing Unit, Family Services Unit and Child Protective Services deferring issues back and forth to one another without appropriate action ever being taken,” the report reads. “There was failed internal communication at DCYF, within all units, to properly communicate concerns regarding this family. This resulted in a failure to take appropriate action in many instances and left children at risk.”

A troubling lack of oversight was revealed in the report, which indicated that there were gaps up to eight months long in some of the children’s cases between face-to-face visits. There was also a huge problem associated with the licensing of Rothgeb’s multiple adoptions, which all utilized home study information from her 2007 and 2011 applications – which, in the case of her final adoption, didn’t even have the correct home address, as Rothgeb had moved to an entirely different home.

The report also states that DCYF relied far too heavily on the statements given by Rothgeb, but also failed to take seriously that, by her own admission multiple times, that she was unable to attend to important things – like accompanying Zah-Nae to the hospital after a seizure – because she had too many children to look after.

“[Rothgeb] was heavily relied upon to provide updates to DCYF regarding the progress of the children with services. Additionally, they sought updates regarding the child’s health and progress with medical appointments directly from the foster mother. There is little to no documentation DCYF staff followed up with service providers or medical professionals.”

The Child Advocate completed depositions with six DCYF employees, including two licensing administrators, a social caseworker and two caseworker supervisors. Their testimony revealed that staffing was a crucial reason why so many incidents went without proper investigation, and why there was a lack of proper licensing procedure.

“Quite frankly, with the number of cases that they all have or the number of homes assigned to them there would be no way for them to be able to visit every foster home or entity that they have on their case load,” one of the licensing administrators testified. That administrator said they would need five to eight additional people in licensing, while the other administrator said 13 to 15 more employees would be required to “do the work properly.”

21 recommendations

In total, the Child Advocate report made 21 recommendations to DCYF, including implementing more stringent review and training processes for all front-line staff and additional hiring of front-line staff in all divisions.

A statement released by Trista Piccola, director for DCYF, indicated a willingness to take these recommendations and improve the system.

“I share the Child Advocate’s concerns about the handling of this case and embrace many of its recommendations, which are closely aligned with the reforms being carried out across DCYF in the aftermath of this tragedy,” she said. “I look forward to fully reviewing the Child Advocate’s findings and will work in cooperation with her to implement additional steps based on her findings. From our frontline staff to our leadership team, DCYF is working in lockstep to ensure that impactful and immediate improvements are made to how Rhode Island protects its children. This solemn responsibility requires the entire community, as noted in the Child Advocate’s report. DCYF is committed to strengthening our relationships with foster families, providers, schools and all other community partners.”