Samantha Rose Gutierrez died before she learned to walk.
She was a year old when paramedics found her cold, stiff body on the floor of a cramped bedroom in the Anaheim house where she lived with her family.
She had been dead hours before the 911 call that summoned paramedics, said Richard Chavez, which troubled the 29-year veteran who was one of four firefighters to respond on the morning of March 26, 2002.
In emergency cases, Chavez said, they rarely find babies who have been dead very long because most caretakers are constantly checking on them and usually notice quickly when something is wrong.
"Even when we get there too late, the body is still warm," he said.
Chavez immediately suspected something was amiss. So did others.
A couple who had lived with the child's family, a local child advocacy group, the Orange County Social Services Agency and the judge who placed her three siblings in protective custody all say Samantha had been abused by her parents, Jacquelyn Starr and Luis Alfonso Gutierrez.
The Orange County coroner's office has ruled her death a homicide. Samantha starved to death, the coroner said. She also had bruises and fractured bones.
Yet more than a year later, no one has been held accountable. Anaheim police say they completed their investigation and forwarded it to prosecutors last August. The district attorney's office declined to discuss Samantha's case with The Times, except to say that prosecutors were meeting with coroner's officials last week.
Samantha's parents could not be reached for an interview. A relative said they have been advised by their attorneys from the Orange County public defender's office not to discuss the case. The lawyers who represented them in the custody case did not return calls seeking comment.
Every year, overworked state social workers receive 700,000 reports of possible child abuse, with allegations ranging from general neglect to beatings.
In Orange County, that number was about 26,000 last year. A handful of those children fall through the cracks. Last year, three Orange County abuse cases ended in a child's death, according to the Social Services Agency.
While the agency cannot disclose names and other details, spokeswoman Deborah Croner said a mother was arrested and charged in one case. In a second, a baby was born to a drug-addicted mother, but died of natural causes so no charges were filed.
The third was Samantha Gutierrez. This is her story.
Dulce Soriano knew Samantha for all of the girl's brief life. Soriano, her husband Luis, and their two children shared a two-bedroom converted garage with the Gutierrez family.
Samantha was an affectionate baby, said Soriano, 28, but cried constantly, and her mother paid little attention to her. Soriano said she cared for Samantha often.
"At that age, babies start grabbing things and try to walk," Soriano said. "The poor thing had no strength in her legs and she couldn't stand up. She was very weak."
A pathologist for the coroner's office listed Samantha's cause of death as ketoacidosis, an imbalance of acids in the blood due to starvation. Samantha, the pathologist concluded, had been neglected to death.
That finding was disputed last year by another pathologist hired by the Gutierrezes' defense attorneys for a court hearing in November to determine custody of Samantha's two brothers, then 5 and 2, and a 1-month-old sister. All had been removed from their home shortly after Samantha's death.
Court records made public May 1 show that a pediatrician who saw Samantha the day before she died did not believe she was malnourished either. The mother told social workers she had taken the baby to see a doctor because she believed Samantha had the flu, according to court records.
Police have pointed to these inconsistencies as a possible reason for a delay in prosecuting the Gutierrezes. The parents may have neglected Samantha, but it is not clear she died at their hands, Anaheim Police Sgt. Rick Martinez said. Superior Court Judge Luis Rodriguez, who oversaw the Gutierrezes' custody hearing, disagreed, according to the appeals court records.
"There is overwhelming evidence of multiple acts of abuse and neglect of the parents and a corroborated history," Rodriguez ruled. Although doctors and scientists may disagree on the exact mechanism that triggered Samantha's death, the judge noted that even the defense expert concurred Samantha had been abused and the "court can reasonably infer that this led to this child's death."
The three surviving Gutierrez children were placed in foster care, according to court records. The Gutierrezes appealed that decision, but the higher court agreed in late April with Rodriguez.
Court records show social workers believed as early as December 2001 that then 9-month-old Samantha was the victim of neglect.