PROVIDENCE, R.I. (WPRI) — Gov. Gina Raimondo said more changes are possible at the state’s Department of Children, Youth and Families after the release Tuesday of a bombshell report from the DCYF’s oversight agency, the Office of the Child Advocate.

The report, compiled in the wake of the death of a 9-year-old Warwick girl in January, concludes that “the actions, or inactions of DCYF staff contributed to the death of this child.”

The child, Zha-Nae Rothgeb, was found unresponsive in a bathtub inside her adoptive mother’s squalid home on Jan. 3. Police said she had been left alone in the tub for hours.

The child advocate’s report details foster mother Michele Rothgeb’s history with DCYF — from her initial failure to become a foster parent because of a criminal past that included incarceration, to her gaining DCYF permission to care for up to eight disabled children at once.

In all, Rothgeb fostered or adopted 13 disabled children over the course of eight years, including Zha-Nae.

“DCYF with its social workers, supervisors and administrators, created this situation,” the report states. “Over the course of thirteen years, they had multiple opportunities to intervene.”

Asked Wednesday whether she still had confidence in DCYF Director Trista Piccola, Raimondo said yes. Piccola has been in the job since early 2017.

“The department is functioning better today by far than it was when she took over,” Raimondo said. “There’s just a mountain of work ahead of us, and frankly tragedies like this aren’t acceptable and show we have more work to do.”

House Oversight Committee Chairwoman Patricia Serpa has called a hearing on Thursday to review the report.

Piccola was not available for an interview Wednesday, the day after the report’s release, but issued a statement to Eyewitness News:

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. 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.

Piccola had addressed Zha-Nae’s death and released the findings of her own department’s investigation back in April. At the time she said five workers had been disciplined and three were no longer working for DCYF.

The child advocate’s report revealed that those three workers were not fired as a result of the DCYF probe; Piccola explained in the report, “these three individuals did not leave as a result of this case. They previously left state government.”

DCYF declined to identify the workers to the child advocate’s office.

The report paints a painfully detailed picture of a single foster parent taking on more and more disabled children until tragedy struck.

The Office of the Child Advocate said Rothgeb’s application to be a generic foster home should have been denied in 2011; instead it was approved and expanded upon over the course of several years.

During that time, some of the foster children’s biological parents requested — sometimes repeatedly — that their children be removed from Rothgeb’s home, and in at least two cases provided the names of family members with whom their children could be placed instead. The report said it’s unclear what steps DCYF took to place the children with those relatives.

In one case, a service provider contacted DCYF’s social worker at least eight times with concerns regarding Rothgeb. None were appropriately documented or followed up on, according the report.

One social worker who was interviewed for the report said DCYF placed a child at Rothgeb’s home because “no other placements were available in Rhode Island.”

A social worker told the child advocate that caseloads are high at the agency. One worker had 18 cases and 32 children. The report also found the DCYF’s licensing unit is short-staffed, and workers there said they need between five and 15 more employees.

Rothgeb — who had previously served a year in prison for a receiving stolen goods charge out of Indiana — was caught in 2013 trying to sell prescription formula on Craigslist, something the report said could be a federal offense. No one questioned why there was excess formula for her to sell, or if the child was eating enough, according to the report.

In 2014, a child protective investigator warned DCYF that “we have placed too many children with her that are so close in age that require a lot of attention … I definitely think the number of children is a safety concern.”

The report details how Rothgeb often kept her children clothed only in diapers (even in the winter), sitting in high chairs, restrained, or in beds covered with zippered netting — especially if she went out and left the children in the care of her 14-year-old autistic grandson.

In January 2018, one year before Zha-Nae was found dead, a child protective investigator told DCYF the home was cluttered and smelled of urine, and Rothgeb refused to let workers into the second floor bedroom area.

By April 2018 Rothgeb had been indicated for neglect, and in July a worker reported being very concerned about the placement of any additional children in her home.

Then the report says, “there is no further contact with this family until six months later in January 2019.” On Jan. 3, 2019, Zha-Nae was found unresponsive on her stomach in a bathtub.

The beds in her room were covered in vomit and urine, according to the report. At the time, the home was described as deplorable with a strong odor of feces and urine, with dozens of soiled diapers piled in some rooms. Child protective services removed the children, and Rothgeb appeared emotionless, according to the report.

Rothgeb, who also faces charges of cruelty to or neglect of a child, is set to be arraigned on her new charge of manslaughter on June 28.