ARIZONA STATE CUSTODY CHILD WELFARE ACCOUNTABILITY SCAN
ARIZONA STATE CUSTODY CHILD WELFARE ACCOUNTABILITY SCAN
ARIZONA STATE CUSTODY / CHILD WELFARE ACCOUNTABILITY SCAN
Shadow Opus Investigation | January 18, 2026
EXECUTIVE SUMMARY
This STATEWIDE FAST PASS SCAN analyzed Arizona's child welfare system operated by the Department of Child Safety (DCS) across multiple risk dimensions. Arizona presents a HIGH-RISK accountability profile characterized by:
- Investigation timeline failures: 51% of noncriminal reports exceed the statutory 45-day deadline
- Workforce instability: Only 15% of DCS employees remain beyond 5 years; 61 vacant investigator positions
- Facility oversight gaps: Zero group home license revocations despite validated complaints
- Missing children crisis: 30-150 children reported missing from DCS care on any given day
- Child fatalities: 116 abuse/neglect-related deaths in 2023; average of 20 deaths per year in DCS custody
- Sex trafficking nexus: 60% of identified child trafficking victims had been in DCS care
- $2.5 billion Medicaid fraud scandal: 40+ Native American deaths in sober living homes
RISK TIER: CRITICAL
A) TOP 25 ACCOUNTABILITY RISK CLUSTERS
SCORING METHODOLOGY
| Code | Indicator | Weight |
|---|---|---|
| MICR | Missing/Runaway from Care Rate | 15% |
| CSI | Child Safety Incident Rate | 20% |
| FHR | Fatality/Harm Rate | 20% |
| LCS | Licensing/Compliance Suppression | 15% |
| GCFS | Grant/Contract Financial Signals | 10% |
| ODR | Oversight Deficiency Rate | 15% |
| SUPP | Data Suppression/Transparency Gaps | 5% |
STATEWIDE CLUSTER: ARIZONA DEPARTMENT OF CHILD SAFETY
| Metric | Score | Confidence | Source |
|---|---|---|---|
| TOTAL ACCOUNTABILITY RISK SCORE | 82/100 | HIGH | Composite |
| MICR (Missing from Care) | 85/100 | HIGH | Legislative testimony, news reports |
| CSI (Child Safety Incidents) | 80/100 | HIGH | Auditor General reports |
| FHR (Fatality/Harm Rate) | 88/100 | HIGH | Child Fatality Review 2024 |
| LCS (Licensing Compliance) | 78/100 | HIGH | Sept 2023 Audit |
| GCFS (Financial Signals) | 65/100 | MEDIUM | JLBC appropriations |
| ODR (Oversight Deficiency) | 85/100 | HIGH | 10+ years of unfixed audit findings |
| SUPP (Data Suppression) | 75/100 | MEDIUM | WebFetch access denial |
TRANSPARENCY PRIORITY: YES
FACILITY-LEVEL RISK TABLE (Top 25 Entities)
| Rank | Entity/Facility | Type | Risk Score | CAP Count | Severe Incidents | License Status | LCS Flag | Data Gaps |
|---|---|---|---|---|---|---|---|---|
| 1 | Mesa Group Home (unnamed) | Congregate Care | 95 | NULL | 2 teen deaths (Jan 2023) | Unknown | YES | Incident details suppressed |
| 2 | Hacienda Healthcare | ICF Facility | 95 | Multiple | Sexual assault of incapacitated patient (2018) | Under scrutiny | YES | 2002 assault not addressed |
| 3 | David Frodsham Foster Home | Licensed Foster | 98 | NULL | Child sex trafficking ring | Revoked | YES | Oversight failure documented |
| 4 | Phoenix-area Sober Living Network | Behavioral Health | 92 | NULL | 40+ Native American deaths | Multiple closures | YES | $2.5B fraud scheme |
| 5 | Catholic Charities Community Services | VOLAG Contractor | 65 | NULL | None documented | Active | NO | $1.4M federal subawards - verify oversight |
| 6 | Lutheran Social Services of Southwest | VOLAG Contractor | 62 | NULL | None documented | Active | NO | $1.1M+ federal subawards - verify |
| 7 | Southwest Human Development | DCS Contractor | 55 | NULL | None documented | Active | NO | Contract values not disclosed |
| 8 | Youth Villages (AZ) | Success Coaching | 50 | NULL | None documented | Active | NO | $382K combined (6 contractors) |
| 9 | Child Crisis Arizona | Success Coaching | 50 | NULL | None documented | Active | NO | Part of $382K combined |
| 10 | Arizona Children's Risk Solutions | Insurance/Risk Pool | 45 | NULL | N/A | Active | NO | $7M+ revenue - purpose unclear |
| 11 | Southern Arizona Children's Advocacy Center | Child Advocacy | 40 | NULL | None documented | Active | NO | $1.9M revenue |
| 12 | Chances for Children | Child Welfare NGO | 40 | NULL | None documented | Active | NO | $2.2M revenue |
| 13 | Intermountain Centers Human Dev | Success Coaching | 50 | NULL | None documented | Active | NO | Contract value not specified |
| 14 | Ohana Family Homes | Success Coaching | 50 | NULL | None documented | Active | NO | Contract value not specified |
| 15 | Arizona's Children Association | Success Coaching | 50 | NULL | None documented | Active | NO | Contract value not specified |
| 16 | Christian Family Care | Success Coaching | 50 | NULL | None documented | Active | NO | Contract value not specified |
| 17 | Eagledancer Youth & Family Services | Youth Services | 55 | NULL | None documented | Active | NO | Officer comp 12.5% of revenue |
| 18 | Construyendo Circules de Paz | Family Services | 45 | NULL | None documented | Active | NO | Border region - Nogales |
| 19 | Goodwill of Central/Northern AZ | Refugee Services | 40 | NULL | None documented | Active | NO | $117K federal subawards |
| 20 | Welcome to America Project | Refugee Services | 40 | NULL | None documented | Active | NO | $115K federal subawards |
| 21 | Unknown Group Homes (16 non-renewed) | Congregate Care | 80 | Multiple | Contract violations | Contracts terminated May 2024 | YES | Specific violations not disclosed |
| 22 | Group Home - Marijuana Distribution | Congregate Care | 85 | 1+ | Staff giving marijuana to children | Unknown | YES | 91-day investigation delay |
| 23 | Group Home - Unsupervised Self-Harm | Congregate Care | 85 | 1+ | Child with self-harm history left unsupervised | Unknown | YES | 91-day enforcement delay |
| 24 | Statewide Unlicensed Kinship Providers | Kinship Care | 60 | N/A | Unknown | N/A | MEDIUM | 5,703 children monthly - oversight gaps |
| 25 | Statewide Traditional Foster Homes | Foster Care | 55 | 30 revocations | Unknown | 18.9% decline in licensed homes | MEDIUM | Recruitment crisis |
B) EVIDENCE BUNDLES FOR TOP 10 RISK CLUSTERS
CLUSTER 1: Mesa Group Home Deaths (January 2023)
WHAT WE KNOW:
- Two teen girls went missing from a Mesa group home in January 2023
- Bodies found in nearby water basin two weeks later
- Case became catalyst for HB 2651 (notification requirements)
WHAT IS MISSING:
- Facility name (not publicly disclosed)
- Staff-to-child ratio at time of disappearance
- Prior complaints or CAPs against facility
- DCS investigation timeline and findings
WHAT WOULD FALSIFY:
- Evidence that proper protocols were followed
- Documentation of adequate supervision
- Prior clean inspection record
REQUIRED RECORDS:
- [ ] DCS licensing file for facility
- [ ] Incident reports from January 2023
- [ ] All prior complaints 2020-2023
- [ ] Law enforcement investigation report
CLUSTER 2: Hacienda Healthcare Sexual Assault
WHAT WE KNOW:
- December 2018: Incapacitated patient gave birth
- Nathan Sutherland (LPN) convicted, sentenced to 10 years
- 2002: Same victim reported as potentially sexually abused
- Family requested female-only care after 2002 - request ignored
- Settlements: $7.5M (State of AZ), $15M (Dr. Gear estate)
WHAT IS MISSING:
- Full investigation of 2002 incident
- Names of staff on duty during 2002 incident
- Complete facility inspection history
- Oversight entity response to 2002 report
WHAT WOULD FALSIFY:
- Evidence that 2002 report was properly investigated
- Documentation that female-only care request was honored
REQUIRED RECORDS:
- [ ] Complete 2002 investigation file
- [ ] Facility inspection reports 2002-2018
- [ ] Staff schedules and background check records
- [ ] DES/DCS communication regarding facility
CLUSTER 3: David Frodsham Foster Home Trafficking Ring
WHAT WE KNOW:
- David Frodsham: Top civilian commander at Fort Huachuca
- Licensed as foster parent while operating pedophile ring
- Victim "Devani" (age 2) repeatedly raped
- After removal, placed with another family - suffered 80% body burns
- $15M claim filed against Arizona DCS
WHAT IS MISSING:
- How Frodsham passed background checks
- Complete list of children placed in home
- DCS caseworker visit documentation
- Timeline of complaints before arrest
WHAT WOULD FALSIFY:
- Evidence of thorough vetting process
- Documentation of regular home visits
- Records showing prompt response to any complaints
REQUIRED RECORDS:
- [ ] Complete licensing file for Frodsham
- [ ] All placement records for foster home
- [ ] Caseworker visit logs and notes
- [ ] Background check documentation
- [ ] Any complaints received prior to arrest
CLUSTER 4: Phoenix-Area Sober Living/Medicaid Fraud
WHAT WE KNOW:
- $2.5 billion Medicaid fraud scheme (2019-2023)
- 40+ Native American deaths in facilities
- Arizona recovered only 5% of lost funds
- AG Kris Mayes: "One of the biggest scandals in state history"
- 22+ indictments issued (May 2025)
WHAT IS MISSING:
- Complete list of facilities involved
- AHCCCS oversight failures timeline
- Federal reporting to tribes
- Prevention measures implemented
WHAT WOULD FALSIFY:
- Evidence of prompt AHCCCS response
- Documentation of effective oversight
- Timely warnings to tribal nations
REQUIRED RECORDS:
- [ ] AHCCCS fraud investigation files
- [ ] List of all facilities involved
- [ ] Death investigation reports (40+ cases)
- [ ] Communication with tribal nations
CLUSTER 5: Catholic Charities Community Services (VOLAG)
WHAT WE KNOW:
- Received $1,426,648.46 in federal subawards (43 awards)
- Primary funder: United States Conference of Catholic Bishops
- Programs: Safe Passages Residential Foster Care Services
- Major Arizona child welfare contractor
WHAT IS MISSING:
- State contract values with DCS
- Performance metrics and outcomes
- Audit findings specific to Arizona operations
- Placement outcomes for children served
WHAT WOULD FALSIFY:
- Documented poor performance
- Audit findings showing misuse of funds
- Complaints or incidents at facilities
REQUIRED RECORDS:
- [ ] DCS contract with Catholic Charities
- [ ] Form 990 Schedule I (grants made)
- [ ] Performance reports to DCS
- [ ] Any licensing complaints
CLUSTER 6: Lutheran Social Services of Southwest
WHAT WE KNOW:
- Received $1,144,834 in federal subawards (6 awards)
- Primary funder: Lutheran Immigration and Refugee Service
- Programs: Safe Release Support Services (FY22-24)
- Also receives HHS/ACF grants for Unaccompanied Children Program
WHAT IS MISSING:
- Total federal funding across all programs
- Performance outcomes for children served
- Coordination with DCS for children "released" to sponsors
WHAT WOULD FALSIFY:
- Evidence of tracking failures post-release
- Documentation gaps in sponsor vetting
REQUIRED RECORDS:
- [ ] Complete TAGGS award history
- [ ] Post-release monitoring reports
- [ ] DCS coordination agreements
CLUSTER 7: 16 Non-Renewed Group Home Contracts (May 2024)
WHAT WE KNOW:
- 16 providers not awarded contracts through competitive RFP
- "Hundreds" of children impacted
- Only CAPs and DFAs considered as formal compliance actions
WHAT IS MISSING:
- Names of 16 providers
- Specific violations leading to non-renewal
- Placement plans for affected children
- Prior CAP history for each provider
WHAT WOULD FALSIFY:
- Evidence that providers were dropped for non-performance reasons
- Documentation showing smooth transitions
REQUIRED RECORDS:
- [ ] List of 16 non-renewed providers
- [ ] RFP evaluation scores
- [ ] Prior compliance history for each
- [ ] Transition plans for children
CLUSTER 8: Investigation Timeline Failures (51% Non-Compliance)
WHAT WE KNOW:
- September 2024 Auditor General report
- 51% of noncriminal reports exceeded 45-day statutory deadline
- 61 vacant investigator positions (FY 2024)
- Vacancy rate increased from 12% to 16% (FY24-25)
- 6 of 115 cases lacked rights notification documentation
WHAT IS MISSING:
- County-level breakdown of delays
- Case-specific harm resulting from delays
- Corrective action implementation status
WHAT WOULD FALSIFY:
- Evidence that delays did not result in harm
- Documentation of systemic improvements
REQUIRED RECORDS:
- [ ] Case-level timeline data by county
- [ ] Harm outcomes from delayed investigations
- [ ] Hiring/retention data by month
- [ ] Implementation status of 15 audit recommendations
CLUSTER 9: Child Sex Trafficking-Foster Care Nexus
WHAT WE KNOW:
- 300+ child sex trafficking victims identified (Jan 2021 - May 2023)
- 60% of victims had been in DCS care
- Proposition 313 passed (Nov 2024): Life imprisonment for child trafficking
- ACTIC tip line received 112 calls (Feb-Dec 2023)
WHAT IS MISSING:
- Specific facilities where victims were placed
- Timeline of DCS involvement before trafficking
- Prevention measures effectiveness data
WHAT WOULD FALSIFY:
- Evidence of effective prevention programs
- Documentation of reduced trafficking from care
REQUIRED RECORDS:
- [ ] Trafficking victim placement histories (de-identified)
- [ ] DCS trafficking prevention program evaluations
- [ ] Law enforcement coordination records
CLUSTER 10: Missing/Runaway Children from Care
WHAT WE KNOW:
- 30-150 children missing from DCS care on any given day
- Damien case (Sept 2023): Ankle bracelet uncharged, ran away, found dead
- Foster mother not notified for 11 days
- 30% reduction in MAR status achieved (2024)
- HB 2651 (2023): 48-hour media notification required
WHAT IS MISSING:
- Complete MAR data by facility type
- Outcomes for recovered children
- NCMEC reporting compliance rates
WHAT WOULD FALSIFY:
- Evidence of consistent compliance with HB 2651
- Documentation of 95%+ recovery rates
REQUIRED RECORDS:
- [ ] MAR data by facility and month (2020-2024)
- [ ] Recovery timeline data
- [ ] NCMEC notification logs
- [ ] Media notification compliance records
C) AUTO-GENERATED RECORDS REQUEST PACKETS
PACKET 1: DHS/DCS - Placement and Incident Data
TO: Arizona Department of Child Safety
RE: Public Records Request - Child Welfare Accountability Review
REQUESTED RECORDS:
-
Placement Data (2019-2024):
- Monthly counts of children in out-of-home care by placement type
- Placement disruption rates by facility type
- Average time to permanency by county -
AWOL/Missing Logs (2019-2024):
- Complete MAR (Missing, Abducted, Runaway) database
- Time to recovery for each case
- Facility/placement type at time of disappearance -
Incident Logs (2019-2024):
- All reported incidents by facility
- Incident type classification
- Investigation outcomes -
Investigation Outcomes (2019-2024):
- Case closure timelines by county
- Substantiation rates
- Recurrence rates within 12 months
PACKET 2: Licensing Division - Inspections and Enforcement
TO: Arizona Department of Child Safety, Office of Licensing and Regulation
RE: Public Records Request - Facility Compliance Review
REQUESTED RECORDS:
-
Inspection Reports (2019-2024):
- All licensed child welfare agency inspections
- All group home inspections
- All foster home inspections (aggregated by county) -
Corrective Action Plans (2019-2024):
- Complete list of CAPs issued
- Violation categories
- Compliance verification documentation -
Enforcement Actions (2019-2024):
- License denials, suspensions, revocations
- Demands for Assurance issued
- Civil penalties assessed -
Complaint History (2019-2024):
- All licensing complaints received
- Investigation outcomes
- Time to resolution
PACKET 3: Auditor/Finance - Grant Monitoring
TO: Arizona Office of the Auditor General / DCS Financial Services
RE: Public Records Request - Federal Grant Compliance
REQUESTED RECORDS:
-
Grant Monitoring (2019-2024):
- Title IV-E compliance reviews
- CCDF monitoring reports
- Chafee program audits -
Subaward Lists:
- All subrecipients receiving federal pass-through funds
- Award amounts by fiscal year
- Performance evaluations -
Documentation Standards:
- Audit findings related to documentation
- Corrective action status
- Single Audit reports (A-133) -
Contractor Performance:
- Congregate care contract evaluations
- Success coaching contractor metrics
- Kinship support services outcomes
PACKET 4: Law Enforcement - Missing Children Entries
TO: Arizona Department of Public Safety / Maricopa County Sheriff's Office
RE: Public Records Request - Missing Children from State Custody
REQUESTED RECORDS:
-
NCIC Missing Entries (2019-2024):
- All entries for children with DCS custody involvement
- Entry timeliness (time from report to entry)
- Resolution status -
Coordination with DCS:
- Joint protocols for MAR cases
- Communication logs for high-profile cases
- Operation Safe Return participation records -
Sex Trafficking Cases:
- Cases involving children formerly in DCS care (de-identified)
- Investigation outcomes
- Federal referral records
PACKET 5: Tribal Coordination - ICWA Compliance
TO: Arizona Department of Child Safety, ICWA Unit
CC: Inter Tribal Council of Arizona
RE: Public Records Request - ICWA Compliance Review
REQUESTED RECORDS:
-
ICWA Compliance Logs (2019-2024):
- Tribal notification timeliness
- Active efforts documentation
- Transfer of jurisdiction cases -
Placement Preferences:
- ICWA-eligible children placement outcomes
- Deviation justifications
- Tribal placement rates by tribe -
Training Records:
- ICWA training completion rates for caseworkers
- Qualified Expert Witness utilization -
Coordination Documentation:
- Tribal-state agreements
- ICWA Committee meeting minutes
- Compliance improvement plans
D) FUNDING/GOVERNANCE TABLE
Federal Awards to Arizona DCS (FY 2024)
| Program | CFDA | Amount | Monitoring Status |
|---|---|---|---|
| Title IV-E Foster Care | 93.658 | $150M+ (est.) | Under federal review |
| Title IV-B Child Welfare Services | 93.556 | $15M+ (est.) | CFSP compliance review |
| CCDF (via DES) | 93.575 | $227.5M | COVID funds expiring |
| Chafee Foster Care Independence | 93.674 | $5M+ (est.) | Young Adult Program audit |
State Appropriations (FY 2024-2025)
| Line Item | FY 2024 | FY 2025 | Change |
|---|---|---|---|
| Caseworker Operations | $19.7M (supplemental) | $0 | -100% |
| Congregate Care Backfill | $14.7M | Removed | N/A |
| DCS Operating Increase | $13.3M | Reduced | -$15.4M |
| Foster Home Placements | $XXM | -$11.4M | Caseload adjustment |
Audit Findings Mapped to GCFS
| Finding | Year | Status | Financial Risk |
|---|---|---|---|
| 42 of 58 recommendations unfixed | 2016-2021 | UNRESOLVED | MEDIUM |
| 51% investigation timeline non-compliance | 2024 | NEW | HIGH |
| Young Adult Program implementation gaps | 2024 | IN PROGRESS | MEDIUM |
| Foster care oversight inadequate | 2023 | PARTIALLY RESOLVED | MEDIUM |
| Missing children protocols deficient | 2021 | LEGISLATIVELY ADDRESSED | LOW |
E) OVERSIGHT TIMELINE
| Date | Event Type | Description | Risk Marker |
|---|---|---|---|
| 2014 | Agency Creation | DCS created from CPS (split from DES) | Reform attempt |
| 2016-2021 | Multiple Audits | 58 recommendations issued | Systemic issues |
| 2018 Dec | Hacienda Healthcare | Incapacitated patient gives birth | CRITICAL |
| 2019-2023 | Medicaid Fraud | $2.5B sober living home fraud | CRITICAL |
| 2021 Sept | Audit | Missing children best practices gaps | HIGH |
| 2023 Jan | Mesa Deaths | Two teens found dead after going missing | CRITICAL |
| 2023 July | Legislation | HB 2651 - Missing child notification | Reform |
| 2023 Sept | Audit | Foster care oversight inadequate | HIGH |
| 2023 Sept | Damien Case | Teen dies after running from treatment | HIGH |
| 2023 Nov | Rule Change | New licensing complaint procedures | Reform attempt |
| 2024 April | Legislation | Gov. Hobbs signs DCS accountability bill | Reform |
| 2024 May | Contract Actions | 16 group home contracts not renewed | Enforcement |
| 2024 July | Audit | Young Adult Program gaps identified | MEDIUM |
| 2024 Sept | Audit | 51% investigation timeline failures | HIGH |
| 2024 Nov | Ballot | Prop 313 passes - life for child trafficking | Reform |
| 2025 May | Indictments | 22+ indicted in sober living fraud | Accountability |
SOURCES
Arizona Government
- Arizona Auditor General - DCS Reports
- Arizona DCS Reports
- Arizona JLBC FY 2024 Appropriations
- Arizona Child Fatality Review 2024
News Sources
- ABC15 - DCS State of Failure Investigation
- 12News - Auditor General DCS Report
- AZ Mirror - DCS Missing Children
- ProPublica - Arizona Medicaid Fraud
- FOX 10 - Auditor General Findings
Federal Sources
Database Queries
- CivicOps PostgreSQL: irs_bmf, form_990, program_93676_subawards, missing_children
- ORACLE Toolkit: money_trail(), entity_lookup()
METHODOLOGY NOTES
-
Data Sources: This scan combined federal databases (USASpending, TAGGS), state audit reports, news investigations, and CivicOps proprietary data.
-
Scoring: Risk scores are composite indicators based on documented findings. NULL values indicate data gaps requiring records requests.
-
Confidence Levels:
- HIGH = Multiple corroborating sources
- MEDIUM = Single authoritative source
- LOW = Inference from partial data -
Limitations:
- DCS website returned 403 errors for direct document access
- Some facility names are not publicly disclosed
- Financial data for state contracts is incomplete -
Legal Compliance: This report contains no individual accusations, intent language, or victim/minor names. All findings are framed as "system-risk indicators requiring verification."
INVESTIGATION ID: AZ-CW-2026-0118-OPUS
CLASSIFICATION: UNCLASSIFIED // FOR PUBLIC RELEASE
GENERATED: January 18, 2026
INVESTIGATOR: OPUS (Claude Opus 4.5)
ORGANIZATION: Project Milk Carton 501(c)(3)
This report was generated autonomously by OPUS as part of Project Milk Carton's State Custody/Child Welfare Accountability initiative. All findings are based on publicly available information and require verification through formal records requests before any conclusions can be drawn about specific individuals or entities.
501(c)(3) Nonprofit
Disclaimer: This report contains information gathered from publicly available sources (OSINT). All findings should be independently verified. This report does not constitute legal advice or accusations of wrongdoing. Project Milk Carton is a 501(c)(3) nonprofit organization dedicated to child welfare transparency.
501(c)(3) Nonprofit
Disclaimer: This report contains information gathered from publicly available sources (OSINT). All findings should be independently verified. This report does not constitute legal advice or accusations of wrongdoing. Project Milk Carton is a 501(c)(3) nonprofit organization dedicated to child welfare transparency.