In the three years before 8-year-old Aurora Williams died of a severe asthma attack, teachers, police and medical providers repeatedly warned Santa Clara County social workers about her living conditions: dog feces in the kitchen, cat urine on her clothes, no food for days and a cockroach crawling up her back, according to newly released records obtained by Bay Area News Group.

“Oh, yeah, bugs just crawl on me,” the child told a medical provider when she was hospitalized last year with an asthma attack, according to a narrative of the call to the county’s child abuse hotline. With each of eight separate referrals made by teachers and others since 2023, social workers concluded every allegation of abuse or neglect was unfounded or inconclusive.

The medical examiner listed “medical neglect” as a significant factor in her death “because of the failure to provide necessary medical care to her on the day she became unresponsive” and deemed it a homicide. Doctors who treated Aurora the morning she was rushed to the hospital — she had stopped breathing — noted that reports describing the “filthy” home “littered with feces and molds” were “clearly a trigger for asthma.”

Only after Aurora’s hospitalization that May morning did social workers deem her house “unlivable” and remove her siblings from the home. They are now in foster care.

While the case is still under investigation, including by law enforcement authorities who are considering whether to file charges, the latest child death has once again renewed scrutiny over the county’s Department of Family and Children’s Services, prompting members of the Board of Supervisors to assail county leadership over its continued troubles and raise the specter of a leadership change. Just last week, another state investigation found “significant system gaps” in the agency that placed vulnerable children with extended family members before completing required safety checks, including criminal background checks.

“We are failing massively,” Supervisor Sylvia Arenas said during a subcommittee meeting established to monitor reforms in the agency since the 2023 fentanyl overdose death of infant Phoenix Castro. “We have Auroras all over this county. We’re failing the children who are in our system who are dying, and the ones who we said ‘no, you’re fine,’ and abuse continued to happen to the point of death.”

County Executive James Williams acknowledged the county has failed in its responsibilities to keep children safe.

“We do need to take a very different approach,” said Williams, who attended the meeting. “With concentrated effort we actually can change the culture, and even if we have systems, structures, and a culture that maybe has been in place for a long time, it can be changed, and it has to be changed.”

The children’s parents were not available for comment. A phone associated with Aurora’s mother has been disconnected, and a man who answered at her home and said he was Aurora’s grandfather, Clay Hanson, said her mother wasn’t available. It wasn’t clear if Aurora’s father also lives there. Hanson said his daughter was “very attentive to all her kids” and that “this whole thing has been blown up” out of proportion.

Each time social workers visited Aurora’s home, they logged the conditions of the house and their suggestions to Aurora’s mother to clean it up and seek therapy. She declined, they reported. Social workers never officially opened a case. They considered the risk to the children “low” to “moderate,” the reports say.

“Although there are concerns regarding the cleanliness of the household and the general appearance of the children,” one of the reports written by a social worker says, “the family appears to be struggling financially and is doing the best they can.”

In more than 100 pages of reports from 2023 to her May 13 hospitalization and death on May 17, social workers and child abuse hotline workers describe conditions in the Williams’ house on Lancelot Lane in East San Jose. Two litter boxes were full and untended in the dining room. Cockroaches climbed up the walls and in and out of kitchen cabinets. Flies swarmed through the house. With three dogs and at least eight cats in the house, animal hair and dander covered furniture.

Aurora was one of seven children, including siblings and half siblings, living in the small house, along with several adult relatives, including an uncle and grandfather. Teachers reported that some of the children looked skinny and malnourished and would complain that they hadn’t eaten in two days. They hoarded school food, stuffing their pockets and backpacks. The Alum Rock School District did not respond to requests for comment.

The county has been under state oversight since soon after the 2023 fentanyl overdose death of baby Phoenix, sent home from the hospital with her drug-abusing father despite warnings from a social worker involved with the family that she wouldn’t be safe there. Investigations by the Bay Area News Group and the California Department of Social Services found that a 2021 policy that focused on family preservation implemented by former DFCS Director Daniel Little, who has since been promoted to head the county’s Social Services Agency, factored into her death.

The state also found that in more than half the cases where children remained with their parents despite safety concerns in the home, safety plans were not developed or monitored and no formal protocols were in place for social workers to follow when families didn’t follow through on their parenting programs.

The state instituted a “corrective action plan” for the county, which it had been following for 18 months when 2-year-old Jaxon Juarez died in April. Reporting by this news organization found that he had been placed in the home of a relative with a  child endangerment felony on her record. The crime should have disqualified her as a foster parent, according to state and county policies. Her teenage son is now charged with Jaxon’s murder and repeated counts of sexual assault.

Earlier this year, Dr. Michelle Jorden, the county’s Medical Examiner, released a report of the Child Death Review Team that found that in 2022, three children who had interactions with county social workers died. In each case, allegations of neglect were determined to be unfounded or inconclusive — leading Jorden to insist in the report that allegations of neglect, especially, be taken more seriously.

In a Friday meeting of the Children, Seniors and Families Committee, chaired by Arenas and vice-chaired by Supervisor Betty Duong, agency Director Wendy Kinnear-Rausch acknowledged the severity of both the recent state report that focused on children placed with extended relatives, as well as the circumstances surrounding Aurora’s death.

“If we were giving ourselves a grade, it would be a failing grade, and I am not one who likes to fail,” Kinnear-Rausch said. “This work is complex and multifaceted. But we have a profound responsibility, and this review indicates that we are not where we need to be.”

When asked by the supervisors to expedite an internal review of the case, she responded, “I don’t want another Aurora, and I don’t have a crystal ball to predict, and I don’t want minimal standards in any sense of everything. But I have to make sure that we do this right.”

According to a Feb. 14, 2025, narrative written by a child abuse hotline worker, and a brief interview with Aurora’s grandfather by this news organization, he had taken Aurora to the hospital that day for asthma and wheezing. That’s when, the report said, the reporting party at the hospital noted that an unidentified bug crawled from her shoe and “a cockroach was observed to crawl out from underneath the child’s upper back.”

That’s when Aurora said “bugs just crawl on me.”

Aurora “was also reported to smell like cat urine” and appeared underweight and pale.

“The child said she is hungry and had not eaten,” the report said. “There is concern about the ability and willingness of the mother to provide adequate hygiene to the child … resulting in concerns for possible neglect.”

On May 13, when Aurora was taken unconscious to the hospital, social workers did a walkthrough of her home and found “the house was determined to be unlivable, with urine on the floor, soiled diapers, insect and cockroach infestation and a sink clogged to the brim with an unknown substance.”

The description was little different from conditions noted by social workers in numerous reports since 2023, but when the remaining children in the home were assessed that May morning, the report said, “the children were not safe to return home due to the living conditions.”

The children’s parents were detained by police then released.

Not until the medical examiner ruled Aurora’s death a homicide with medical neglect as a significant factor — four months after her death — did the county release the referral reports to this news organization and the supervisors.

Supervisor Duong, who read the report, said she “couldn’t get past the first encounter.”

“We should never have left that home,” she said. “We should have never walked away from that child.”

Arenas called for a special Board of Supervisors meeting to discuss Aurora’s death.

“For years, years, years, we’ve just stood on the sidelines and accepted that this is the way it is for children who are poor,” Arenas said.

Only County Executive Williams has the authority to fire agency leaders. Supervisors only have the ability to fire the county executive.

“Wendy characterized it as an F — it’s actually 40 points below an F,” Williams told the supervisors. “What that really speaks to is wholesale culture and structure challenges that we have to address.”

Arenas suggested, as she has numerous times since baby Phoenix’s death, it might be time for new leadership.

“If the right people aren’t there, then the right people aren’t there and we must part ways,” she said. “I have no loyalty for anyone in the system except for the children and families.”