Jazzmin Davis was 15 years old when she was beaten to death. She lived in Antioch with her twin brother and their foster mother. Police called it a house of horrors.
"Beatings of both children with carpet tacks, with sticks, steel rods, that ended breaking in the course of beatings," Darren Kessler, the court-appointed lawyer for Davis' surviving brother, said.
On Sept. 2, 2008, police found the dead teenager and her brother in their feces and urine-soaked bedroom where they were often locked in a closet for days, even months. They looked starved and emaciated.
"They were about 80 pounds, give or take a few pounds," Kessler said. "It was as if theyhad come out of a concentration camp. It was that bad."
The twins' foster mother and aunt, Sheemeka Davis, has been charged with Jazzmin's murder.
In an exclusive interview with ABC7, Kessler said the system failed Jazzmin.
"Staff that were involved with the oversight of the children, the court system, all the players that were involved from one extent to the other dropped the ball here," he said.
He says it began with the San Francisco Human Services Agency, which placed the twins with Sheemeka Davis when they were infants.
"It's very difficult to read the case notes, the police reports and all that, knowing that our agency had a role in this," agency Director Trent Rhorer said.
Rhorer agrees with Kessler that the social worker lied and even ignored warning signs that may have saved Jazzmin's life.
"When they're not doing their job, it's difficult for the system to respond and in this particular case, there were falsified case notes, there were questionable visiting practices of the kids who were in the home," Rhorer said.
Foster children are required to have annual physicals, but there was no mention of medical exams in the social worker's case file.
"I can tell you if there was any doctor who saw these children the way they looked or even half as bad as the way they looked, there would have been a mandatory report to the authorities," Kessler said.
Case workers usually make monthly visits to check on foster children. In Jazzmin's case, the visits were rolled back to twice a year because the case worker never reported problems, even ignoring the children's complaints that they were getting "whoopings."
Kessler says the caseworker's supervisors should have been more vigilant.
"There is a systemic flaw in this system where this problem could happen again and again," Kessler said.
Jazzmin enrolled at Antioch High School the year before she died, even though she never attended classes. But the case worker wrote reports saying Jazzmin was going to school.
"One in particular for Jazzmin said, 'Oh, she's doing about a C average. She's doing well,' and this was at a time when she wasn't even in school. She was being locked in a closet," Kessler said.
Kessler says the Antioch Unified School District also failed Jazzmin by not following up on her truancy.
Since Jazzmin's death, Rhorer says his agency has instituted more stringent checks and balances to make sure this kind of tragedy never happens again. Human Services now requires caseworkers to make unannounced visits every month, without exception.
"In addition we've upgraded our technology to enable supervisors, middle managers and managers to be able to monitor at the caseworker level whether or not visits are held monthly, whether medical appoints are actually followed through, school visits verified," Rhorer said.
Kessler sued the agency and the Antioch Unified School District on behalf of Jazzmin's brother, who turned 18 this year. School officials declined to be interviewed, but ABC7 has learned they settled for $750,000. San Francisco settled for $4 million, one of the largest settlements ever by the city for foster child negligence.
The social worker retired during the investigation of this case. She also was named in the lawsuit. The city settlement covered her liability.