In re K.N. CA4/1 ( 2021 )


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  • Filed 12/3/21 In re K.N. CA4/1
    NOT TO BE PUBLISHED IN OFFICIAL REPORTS
    California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions not certified for
    publication or ordered published, except as specified by rule 8.1115(b). This opinion has not been certified for publication
    or ordered published for purposes of rule 8.1115.
    COURT OF APPEAL, FOURTH APPELLATE DISTRICT
    DIVISION ONE
    STATE OF CALIFORNIA
    In re K.N. et al., Persons Coming
    Under the Juvenile Court Law.
    D079164
    SAN DIEGO COUNTY HEALTH
    AND HUMAN SERVICES
    AGENCY,                                                          (Super. Ct. No. EJ4604)
    Plaintiff and Respondent,
    v.
    I.N. et al.,
    Defendants and Appellants.
    APPEAL from a judgment of the Superior Court of San Diego County,
    Gary M. Bubis, Judge. Affirmed.
    Diana W. Prince, under appointment by the Court of Appeal, for
    Defendant and Appellant I.N.
    Joseph T. Tavano, under appointment by the Court of Appeal, for
    Defendant and Appellant S.M.
    Lonnie J. Eldridge, County Counsel, Caitlin E. Rae, Chief Deputy
    County Counsel, and Eliza Molk, Deputy County Counsel for Plaintiff and
    Respondent.
    INTRODUCTION
    Five-month-old twin sisters, Z.N. and Za.N., were each diagnosed with
    broken blood vessels under the surface of the eye, or subconjunctival
    hemorrhages. The twins were under the sole care and supervision of their
    parents when the injuries presented, and their parents were unable to
    account for how the injuries occurred. A child abuse pediatrician determined
    that under these circumstances, the twins’ injuries likely resulted from
    nonaccidental trauma and indicated a risk of more severe abuse in the future.
    The juvenile court assumed jurisdiction over the twins and their three-
    year-old sibling and returned the children to the parents’ home pursuant to a
    family maintenance plan. I.N. (Father) and S.M. (Mother) appeal from those
    orders, contending there was insufficient evidence to establish the twins
    suffered serious injury inflicted nonaccidentally by the parents, and as such,
    all three children’s petitions should be dismissed. The parents also challenge
    the juvenile court’s dispositional orders conditioning the children’s placement
    in the parents’ custody on their compliance with a family maintenance plan.
    Finding no error, we affirm the juvenile court’s orders.
    FACTUAL AND PROCEDURAL BACKGROUND
    A.    Initiation of Dependency Proceedings and Detention
    Z.N. and Za.N. were born nine weeks premature.1 They were
    hospitalized in the neonatal intensive care unit (NICU) because of their
    1     “ ‘In accord with the usual rules on appeal, we state the facts in the
    manner most favorable to the dependency court’s order.’ ” (In re Janee W.
    (2006) 
    140 Cal.App.4th 1444
    , 1448, fn. 1.)
    2
    premature birth. Upon release from the NICU, they began receiving physical
    therapy, occupational therapy, and other medical services. The twins’ older
    sister, K.N., was also born premature and required early intervention
    services in physical therapy and speech therapy.
    On the morning of February 6, 2021, Mother noticed a red dot in Z.N.’s
    eye. The redness worsened as the day went on, prompting the parents to
    bring her to the emergency room. The emergency room physician diagnosed
    her with a subconjunctival hemorrhage (SCH) to her right eye, and a “[v]ery
    mild” lateral conjunctival hemorrhage in the left eye. Z.N. did not present
    with other signs of injury, trauma, fractures, or bruising. She had no known
    allergies. Although forceful coughing or crying can cause an SCH, the doctor
    found these were unlikely explanations for Z.N.’s injury. Instead, the doctor
    suspected nonaccidental trauma and referred the case to the hospital’s child
    protection team (CPT) for a physical abuse assessment.
    A child abuse physician with the CPT, Dr. Nienow, confirmed that,
    absent a history of accidental trauma, Z.N.’s injury was “highly concerning”
    for physical abuse. Dr. Nienow described the injury as “sentinel,” meaning a
    “seemingly minor injur[y] in non-mobile infants that [is] often [a] harbinger
    for future more serious abusive trauma.” Dr. Nienow indicated that SCHs
    are generally not self-inflicted for children of Z.N.’s age and would not be
    caused by routine infant care or normal infant activity, such as eye rubbing,
    crying, vomiting, or sneezing. Noting that premature infants such as Z.N.
    and Za.N. are at a higher risk of abuse and neglect, Dr. Nienow
    recommended services be provided to support the family and to mitigate the
    risk of future harm.
    After the San Diego County Health and Human Services Agency
    (Agency) was notified by the hospital of Z.N.’s injury, a social worker
    3
    interviewed the parents. Mother had no explanation for Z.N.’s injuries. She
    reported that Father was the children’s primary caretaker, as she worked
    Monday through Friday from 8:00 a.m. to 5:00 p.m. and every other
    Saturday. Only the parents and the three children resided in the home. She
    denied anyone frequently visited the home or cared for the children, and the
    parents were especially cautious due to the COVID-19 pandemic. She
    indicated that older sister K.N. could not have caused the injury, since K.N.
    was not left alone with the twins. Mother also denied that Father could be
    responsible.
    Father largely confirmed Mother’s account during his interview with
    the social worker. As the children’s primary caregiver, he denied that he or
    Mother would have injured Z.N. Father had researched Z.N.’s condition on
    the internet and thought the injury could have been caused by vomiting,
    crying, sneezing, or Z.N. grabbing her own eyes. When the social worker
    explained the doctor’s conclusion that the injury was caused by someone
    pressing on Z.N.’s face or chest, Father denied this ever occurred while he
    was caring for the children. Father also noted the twins have three
    therapists who come to the home three times per week, and that the twins
    cry “a lot” around the therapists and he does not always supervise their
    visits. However, none of the therapists were in the home on February 5, the
    day before Z.N.’s injury presented.
    The Agency attempted to safety plan with the parents, but the parents
    were unwilling to identify a support network or alternate placement options.
    Due to their lack of cooperation, the Agency took protective custody over the
    children and detained them in a foster home.
    4
    On February 10, 2021, the Agency filed a petition under Welfare and
    Institutions Code2 section 300, subdivision (a) on behalf of Z.N., alleging
    there was a substantial risk she would suffer serious physical harm inflicted
    nonaccidentally. Pursuant to section 355.1,3 the petition alleged Z.N. had
    suffered an SCH, a condition which would not ordinarily be sustained except
    as a result of the unreasonable acts of the child’s parents. The Agency also
    filed petitions under section 300, subdivision (j) on behalf of Za.N. and K.N.
    based on the abuse of their sibling. At the detention hearing on February 11,
    the juvenile court appointed counsel for the parents and the children,
    detained the children out-of-home, and ordered the Agency to provide the
    parents with voluntary services. It further ordered supervised visitation for
    the parents.
    Around this time, Za.N. was also diagnosed with an SCH in one eye.
    The foster parent noticed marks in the outside corner of Za.N.’s eye when the
    children arrived at the foster home on February 8, 2021. The twins’ primary
    care provider examined Za.N. on February 10 and diagnosed her with an
    SCH in the right eye. This was the first time the primary care provider found
    an unexplained injury in either twin. When asked by the social worker if she
    believed the twins’ injuries were nonaccidental, the primary care provider
    2    All further statutory references are to the Welfare and Institutions
    Code unless otherwise specified.
    3      Section 355.1, subdivision (a) provides, in relevant part: “Where the
    court finds, based upon competent professional evidence, that an injury,
    injuries, or detrimental condition sustained by a minor is of a nature as
    would ordinarily not be sustained except as the result of the unreasonable or
    neglectful acts or omissions of either parent, . . . that finding shall be prima
    facie evidence that the minor is a person described by subdivision (a), (b), or
    (d) of Section 300.”
    5
    stated “the general teaching is that there is always concern when children of
    that age have injuries like that.” After moving the children from the foster
    home to a children’s center for a few days, the Agency placed the children
    with nonrelative extended family members.
    Za.N. was referred to Dr. Nienow for further examination. Dr. Nienow
    agreed Za.N. had an SCH in one eye, and the presence of this injury
    confirmed her suspicions of physical abuse in the parents’ home. Dr. Nienow
    opined that: “As with [Za.N.’s] sister, there has been no history provided to
    explain [Za.N.’s] injury. Subconjunctival hemorrhages are broken blood
    vessels under the surface of the eye and are the result of direct impact
    trauma to the globe itself, or more rarely secondary to increased intrathoracic
    pressure events. These are not the result of self-inflicted injury in this age
    group, are not caused by routine handling/care or crying/coughing/vomiting,
    nor are they sequela of prematurity or indicators of eye disease. In [the]
    absence of a reasonable accidental trauma history these findings are highly
    concerning for inflicted injury. It is very concerning that this is the second
    child in this family [who] has presented for this kind of trauma, further
    reinforcing the concern for physical abuse.” K.N. was also examined and no
    injuries were identified.
    At the parents’ request, the twins’ ophthalmologist, Dr. Robbins,
    provided letters to the Agency. Dr. Robbins had examined the twins for eye
    conditions following their premature birth, and determined their eyes were
    developing well as of their last exam in November 2020. Even though Dr.
    Robbins found the presence of Z.N.’s injury “alarming,” she indicated there
    were many reasons why infants develop SCHs that are unrelated to abuse,
    such as coughing, sneezing, straining, rubbing, or hitting the eye. She stated
    that most SCHs in infants are caused by the infant hitting themselves in the
    6
    eye or accidentally being hit by a sibling. She also noted that a pediatric
    ophthalmologist had conducted a full dilated eye exam of Z.N. within 24 to 48
    hours of her presenting with the injury, and no other pathology was found.
    Dr. Robbins described the parents as “devoted” and “caring,” and she did not
    suspect any inappropriate behavior during her interactions with them.
    On February 16, 2021, the Agency received a referral indicating that
    K.N. disclosed that Father hit her in the face. Mother confirmed that K.N.
    had made the same disclosure to her during a visit with the children on
    February 16, but both parents denied Father ever hit K.N. or used physical
    discipline. K.N. was examined and received a CT scan, but no injuries were
    noted. K.N. was also interviewed by the social worker but was unable to
    provide any details due to her difficulties communicating.4
    During subsequent interviews with the social worker, the parents
    continued to lack an explanation for the twins’ injuries. Mother maintained
    there was no abuse or neglect in the home and denied that she would benefit
    from services. During his interview, Father confirmed he was the children’s
    primary caregiver and was currently unemployed. He denied ever leaving
    the children unsupervised. He stated he was usually present for the twins’
    in-home therapies, and K.N. was always supervised around the twins.
    Dr. Nienow examined Z.N. and Za.N. during a follow-up appointment
    on February 22, 2021. Their SCHs had completely resolved, and there were
    no further injuries that indicated abuse or neglect. Dr. Nienow had reviewed
    the letters from Dr. Robbins but maintained that the twins’ injuries were
    likely caused by physical abuse. Dr. Nienow noted that SCHs in infants are
    4    Although Father initially indicated that K.N. was autistic, he
    subsequently claimed he had been misquoted and that she had not been
    diagnosed with autism.
    7
    “extraordinarily rare” and are the result of trauma in the majority of cases.
    She repeated her opinion that SCHs would not be, in this age group, the
    result of self-inflicted injury or routine infant care or normal infant activity.
    Following Dr. Nienow’s assessment of Za.N.’s injury, the Agency filed
    an amended petition on Za.N.’s behalf on March 5, 2021, alleging she was a
    child described by section 300, subdivision (a) and that the section 355.1
    presumption applied.
    Pending the jurisdiction and disposition hearing, Z.N. and Za.N.
    underwent bloodwork to determine if either child had a condition that may
    have contributed to their respective injuries. Their bloodwork came back
    normal, and no blood conditions were found. K.N. also participated in a
    forensic interview regarding her disclosure that Father hit her in the face.
    The allegation was deemed inconclusive due to K.N.’s inability to
    meaningfully participate in the interview. As for the parents, they had been
    successfully participating in Agency-approved parenting classes, but stopped
    attending child abuse group classes at some point and refused to resume
    participation unless it was court-ordered.
    Dr. Nienow provided a final assessment regarding her findings on April
    29, 2021. She noted that blood disorders in the twins had been ruled out as a
    cause. She also indicated that other evidence of abuse, such as bruising on
    the face or other areas, is not always seen in conjunction with eye
    hemorrhages if force was applied directly to the eye globe and not to other
    parts of the body. Additionally, there may not be additional injuries or
    bruising if smothering, strangulation, or suffocation was involved.
    B.    Contested Jurisdiction and Disposition Hearing
    The contested jurisdiction and disposition hearing was held over the
    course of several days in May and June 2021. The Agency recommended that
    the juvenile court find the children’s petitions true, continue to detain the
    8
    children out-of-home, and offer the parents family reunification services. It
    further recommended supervised visitation for the parents, with the Agency
    to have the discretion to lift supervision upon the parents’ progress in the
    recommended services. In its reports, the Agency expressed concerns
    regarding the children’s vulnerability given their young ages, complete
    reliance on their parents for protection, and developmental needs. In the
    Agency’s view, the parents’ failure to provide a plausible explanation for the
    twins’ injuries indicated there was a continuing risk of future harm to all
    three children, which could increase in severity.
    At the contested hearing, Mother called Dr. Robbins to testify, and she
    was designated as an expert in medicine and pediatric ophthalmology. Dr.
    Robbins examined the twins twice while they were in the NICU after their
    premature birth, and twice as outpatients in her office. According to Dr.
    Robbins, SCHs could occur for a variety of reasons, although they were
    uncommon in childhood generally, and were generally the most noticeable
    within the first 24 hours. In her opinion, the most common cause of an
    isolated SCH in infants was accidental trauma, such as a finger poke, and an
    infant of the twins’ age possessed the ability to poke themselves in a manner
    that could cause an SCH. Dr. Robbins would not suspect child abuse absent
    additional injuries, and believed that a full eye exam would be necessary to
    accurately determine whether an SCH was caused by abuse. She testified,
    however, that abuse should be considered where the infant presents with an
    SCH and there is no accidental trauma history, and she agreed that SCHs
    can be a sentinel injury. She also agreed it was unusual that each twin
    suffered an SCH around the same time, which “heightened” the concern of
    nonaccidental trauma. She indicated that other than trauma, the second
    most likely cause of an SCH in infants was an infection, but this was a “far
    9
    second.” Dr. Robbins was unable to provide any studies or data to support
    her opinions, and she indicated that she had only prepared to testify as a
    treating physician and not as an expert in child abuse.
    Father called his own expert, Dr. Tawansy, who was also designated by
    the juvenile court as an expert in medicine and pediatric ophthalmology. In
    Dr. Tawansy’s opinion, the twins’ injuries were not related to child abuse but
    rather eye rubbing and eye inflammation caused by a viral infection. Dr.
    Tawansy agreed with Dr. Robbins that a child of the twins’ age could self-
    inflict an SCH. He would also expect to see other physical injuries if an SCH
    had been caused by abuse, such as bruising or other injuries to the eye. Dr.
    Tawansy testified he had not personally examined the twins but formed his
    opinion that their injuries were caused by a virus based on the twins’ medical
    records, information from the foster parents, and photographs of the twins.
    He noted the infants’ eyes looked glazed and there was also evidence of eye
    secretions in the photographs, which indicated to him the existence of a viral
    infection. He believed that where child abuse is suspected, a comprehensive
    eye exam was “mandatory” to make an accurate diagnosis. During cross-
    examination, Dr. Tawansy admitted that his curriculum vitae was out of date
    and did not accurately reflect the hospitals where he had admitting
    privileges. He also admitted that he had been investigated by the California
    Medical Board for violating the standard of care, including combining
    syringes from different patients, and was in jeopardy of losing his surgeon
    certificate and his authority to supervise physicians. He ultimately settled
    the dispute.
    The Agency called Dr. Nienow as its expert. Dr. Nienow testified that
    she evaluates around 1,500 children for suspected child abuse each year. Of
    those cases, she had determined only 50 percent were caused by abuse or
    10
    neglect, while the remaining 50 percent she determined were accidental or
    indeterminate causes. Following this testimony, the juvenile court
    designated Dr. Nienow as an expert in pediatric child abuse.
    Regarding the twins’ injuries, Dr. Nienow testified in line with her
    earlier reports, maintaining that their injuries were most likely caused by
    some form of abuse. Although not an ophthalmologist, Dr. Nienow completed
    a fellowship rotation in ophthalmology, and considered herself an authority
    on eye problems that were commonly presented in pediatrics, including
    SCHs. She testified that SCHs were extraordinarily rare in normal, healthy
    infants, and were caused by direct trauma to the globe in most cases. An
    SCH could be observed immediately and tended to darken during the first 24
    hours. According to Dr. Nienow, the most recent study conducted on
    nonambulatory infants with SCHs found 97 percent of the injuries to be
    related to nonaccidental trauma. Dr. Nienow disagreed with the parents’
    experts that an infant of the twins’ ages could produce enough force to cause
    their own SCHs. She also did not believe that other markings were likely to
    be present if the twins’ injuries were caused by abuse, noting that she had
    seen this before in other infants with SCHs who were abused. She also
    discussed the potential that SCHs were caused by a virus, but found this
    unlikely, noting that the bloodwork for the twins did not indicate a viral
    infection, and the twins had not displayed any other signs or symptoms that
    would suggest a virus had contributed to their injuries. She stated that Z.N.
    and Za.N.’s individual cases were peer-reviewed twice by seven other child
    abuse pediatricians, all of whom agreed with her conclusions. Lastly, Dr.
    Nienow noted that prematurity was a significant risk factor for nonaccidental
    trauma generally, and premature infants were at twice the risk as their
    same-aged normative peers for abuse or neglect.
    11
    Two social workers were also called to testify regarding their reports
    and interactions with the family. The current social worker assigned to the
    children’s cases testified that she believed all three children were at risk of
    abuse given their young ages and various developmental needs, the
    unexplained injuries in the twins, and the parents’ lack of progress in child
    abuse classes. She expressed specific concerns about the Father’s stress level
    as the children’s primary caregiver. She also testified that Father was alone
    with the children on February 5, 2021, from 8:00 a.m. to 5:00 p.m. while
    Mother was at work, and he was also alone with Za.N. the following three
    days while Mother took the other two children to the hospital.
    The juvenile court also heard testimony from one of the in-home infant
    educators for the twins, who had worked with the twins two hours each week
    for eight weeks. Although this educator did not suspect any abuse or neglect
    by the parents, she also did not believe that any of the service providers from
    her company could have caused the twins’ injuries. The foster parent who
    first identified Za.N.’s injury testified she first noticed the injury on the
    evening of February 8, 2021, and that the injury was still observable the
    following morning. She did not observe either twin rub or itch their eyes or
    observe any signs of sickness in either twin.
    The juvenile court also admitted into evidence the Agency’s reports, the
    curriculum vitae for the medical experts, medical records documenting the
    twins’ injuries, and a 45-second video taken by the children’s current
    caregiver showing Za.N. putting her hands on her face and around her eyes.
    The court also admitted the medical articles that Dr. Nienow relied on in
    formulating her opinion, to determine whether the literature supported Dr.
    Nienow’s opinion and not for the truth of the matter asserted in the articles.
    12
    After the close of evidence and closing arguments by counsel, the
    juvenile court addressed the credibility of the witnesses, starting with the
    medical experts. It found Dr. Nienow “highly credible,” noting that she had
    testified in his courtroom before, while Dr. Robbins was also found to be
    “highly qualified” with “very impressive credentials.” However, the court
    expressed reservations about Dr. Tawansy’s credibility, noting that his
    failure to update his resume was “lazy,” and that he gave opinions without
    sufficient evidence to support them. Lastly, the court found the current social
    worker and foster parent credible. As to the social worker, the court
    indicated that he had experience hearing testimony from her in his previous
    cases, and that her reports demonstrated that she is “competent” and
    “professional.”
    The juvenile court made a true finding on the petitions based on a
    preponderance of the evidence and assumed dependency jurisdiction over the
    children. The court concluded that the section 355.1 presumption applied
    and was unrebutted by competent evidence, finding no reasonable
    explanation for the twins’ injuries outside of “just theories.” The court
    disbelieved the testimony provided by the parents’ experts, finding it unlikely
    that infants of the twins’ age would injure their own eyes with the force
    necessary to create an SCH, and that none of the treating doctors noted any
    viral infections. The court expressly found that these were sentinel injuries,
    so although not life-threatening, the existence of the injuries raised the
    potential of future, more serious abuse. The court emphasized these injuries
    were uncommon for children of this age, noting the doctors who had treated
    the twins shared Dr. Nienow’s concerns that the injuries were caused by child
    abuse. The court further noted that, even if the presumption was rebutted, it
    13
    would have still found the children’s petitions true by a preponderance of the
    evidence.
    The juvenile court then ordered the return of the children to their
    parents’ care, conditioned on the parents’ compliance with a family
    maintenance plan. In rejecting the Agency’s request for out-of-home
    detention, the court found that detriment for removal had not been
    established by clear and convincing evidence. The court also expressed
    empathy for the parents’ circumstance and the difficulties in caring for
    premature infants, finding “that anybody who may have had a moment of
    weakness or had a difficult time that potentially caused these injuries would
    not necessarily do them again.” The court concluded that although the
    children could return to their parents’ care, it was necessary to continue
    monitoring the parents under a family maintenance plan to ensure the
    children’s safety. The safety plan required two adults to be present in the
    home at all times; all relatives and support persons who interacted with the
    family pursuant to the safety plan were to provide the Agency with general
    updates and any safety concerns; an assigned advocate would check on the
    family twice per month; and the Agency was authorized to conduct
    announced and unannounced visits. The parents were also ordered to
    participate in child abuse and group parenting courses, and Father was
    required to attend individual therapy if recommended by his child abuse
    group provider.
    Father and Mother timely appealed.5
    5     Although Father and Mother have separately briefed this appeal, they
    have joined the arguments raised in each other’s respective briefs.
    14
    DISCUSSION
    On appeal, the parents contend the evidence before the juvenile court
    was insufficient to support the true findings for jurisdiction under section
    300, subdivisions (a) and (j). They argue the testimony provided by their
    respective experts rebutted the section 355.1 presumption by which the
    subdivision (a) petitions were predicated, and that the evidence failed to show
    the twins suffered serious injury inflicted nonaccidentally by either parent.
    As such, K.N. was not an at-risk sibling under section 300, subdivision (j).
    They also assert the juvenile court abused its discretion by ordering their
    compliance with a family maintenance plan. They further contend that the
    juvenile court was biased against them.
    As we shall explain, even if the statutory presumption was rebutted,
    there is substantial evidence in the record to support the juvenile court’s
    jurisdictional findings. The parents’ challenge to the dispositional orders is
    also unsuccessful because the family maintenance plan was tailored to
    address the best interests of the children and does not otherwise constitute
    an abuse of discretion. Lastly, the parents’ accusations of judicial bias lack
    support in the record.
    A.    The Juvenile Court’s Jurisdictional Findings Are Supported by
    Substantial Evidence
    “The court asserts jurisdiction with respect to a child when one of the
    statutory prerequisites listed in section 300 has been demonstrated.” (In re
    I.A. (2011) 
    201 Cal.App.4th 1484
    , 1491.) Section 300, subdivision (a)
    authorizes the juvenile court to adjudge a minor a dependent child of the
    court when “[t]he child has suffered, or there is a substantial risk that the
    child will suffer, serious physical harm inflicted nonaccidentally upon the
    child by the child’s parent or guardian.” (§ 300, subd. (a).) Subdivision (j)
    provides a basis for jurisdiction when a child’s sibling has been abused or
    15
    neglected under section 300, subdivisions (a), (b), (d), (e), or (i), and there is a
    substantial risk the child will be abused or neglected, as defined in those
    subdivisions. (§ 300, subd. (j); In re Ricardo L. (2003) 
    109 Cal.App.4th 552
    ,
    566.) The juvenile court need only find the allegations of the petition under
    the subdivisions of section 300 true by a preponderance of the evidence.
    (§ 355; Cynthia D. v. Superior Court (1993) 
    5 Cal.4th 242
    , 248; In re Brison C.
    (2000) 
    81 Cal.App.4th 1373
    , 1379.)
    In addition, under section 355.1, “[w]here the court finds, based upon
    competent professional evidence, that an injury, injuries, or detrimental
    condition sustained by a minor is of a nature as would ordinarily not be
    sustained except as the result of the unreasonable or neglectful acts or
    omissions of either parent, . . . that finding shall be prima facie evidence that
    the minor is a person described by subdivision (a), (b), or (d) of Section 300.”
    (§ 355.1, subd. (a).) The presumption created by section 355.1, subdivision
    (a), “constitutes a presumption affecting the burden of producing evidence.”
    (§ 355.1, subd. (c).) Once the Agency establishes a prima facie case under
    section 355.1, the burden of producing evidence “merely shifts to the parents
    the obligation of raising an issue as to the actual cause of the injury or the
    fitness of the home.” (In re James B. (1985) 
    166 Cal.App.3d 934
    , 937, fn. 2
    (James B.) [discussing former section 355.2, section 355.1’s predecessor].)
    “The general rule is that ‘the juvenile court’s exercise of jurisdiction
    over a child will be upheld if substantial evidence supports any one of the
    statutory bases for jurisdiction enumerated in the petition.’ ” (In re M.R.
    (2017) 
    7 Cal.App.5th 886
    , 896.) Under this standard, we consider the entire
    record to determine whether the evidence is “ ‘ “reasonable, credible, and of
    solid value.” ’ ” (In re S.A. (2010) 
    182 Cal.App.4th 1128
    , 1140.) We do not
    pass on the credibility of witnesses, attempt to resolve conflicts in the
    16
    evidence, or weigh the evidence. Instead, we draw all reasonable inferences
    in support of the findings, view the record favorably to the juvenile court's
    orders, and affirm the orders even if other evidence supports a contrary
    finding. (In re Casey D. (1999) 
    70 Cal.App.4th 38
    , 52−53 (Casey D.)
    disapproved of on other grounds by In re Caden C. (2021) 
    11 Cal.5th 614
    ,
    635−636.) Substantial evidence is not synonymous with any evidence. (In re
    Savannah M. (2005) 
    131 Cal.App.4th 1387
    , 1393 (Savannah M.), abrogated
    on different grounds by In re R.T. (2017) 
    3 Cal.5th 622
    , 628−631.) The
    ultimate test is whether, considering the entire record, a reasonable trier of
    fact would make the challenged ruling. (Savannah M., at pp. 1393−1394.)
    We begin our analysis with the statutory presumption set forth by
    section 355.1, subdivision (a). As noted, that presumption is only a
    presumption affecting the burden of producing evidence. (§ 355.1, subd. (c).)
    “ ‘The effect of a presumption affecting the burden of producing evidence is to
    require the trier of fact to assume the existence of the presumed fact unless
    and until evidence is introduced which would support a finding of its
    nonexistence, in which case the trier of fact shall determine the existence or
    nonexistence of the presumed fact from the evidence and without regard to
    the presumption.’ (Evid. Code, § 604.)” (In re D.P. (2014) 
    225 Cal.App.4th 898
    , 903–904 (In re D.P.).) “Thus, when the party against whom such a
    presumption operates produces some quantum of evidence casting doubt on
    the truth of the presumed fact, the other party is no longer aided by the
    presumption. The presumption disappears, leaving it to the party in whose
    favor it initially worked to prove the fact in question.” (Rancho Santa Fe
    Pharmacy, Inc. v. Seyfert (1990) 
    219 Cal.App.3d 875
    , 882.) In comparison, a
    presumption affecting the burden of proof imposes a much more onerous
    burden, placing the burden on the opposing party to disprove the presumed
    17
    fact by a preponderance of the evidence (or other appropriate standard).
    (Evid. Code, § 606; In re Heather B. (1992) 
    9 Cal.App.4th 535
    , 560−561.)
    In this case, we assume without deciding that the parents’ expert
    testimony⎯opining that the twins’ injuries were most likely unrelated to
    abuse⎯was sufficient to rebut the statutory presumption under section
    355.1. (Cf. In re Quentin H. (2014) 
    230 Cal.App.4th 608
    , 615 [evidence in the
    record showing father had always behaved appropriately with his children
    was sufficient to rebut the section 355.1 presumption that his children were
    described by section 300, subdivisions. (b) and (d)]; In re Esmeralda B. (1992)
    
    11 Cal.App.4th 1036
    , 1041 [father rebutted the section 355.1 presumption
    with contradictory evidence in social worker’s report regarding the physical
    cause of the child’s injury]; James B., supra, 166 Cal.App.3d at p. 937
    [discussing section 355.2, section 355.1’s predecessor, and concluding the
    juvenile court erred by applying the statutory presumption where the parents
    had presented rebuttal evidence, which included expert testimony indicating
    that the child’s injuries could have been caused accidentally]; with In re J.L.
    (2014) 
    226 Cal.App.4th 1429
    , 1433−1435 [presumption under section 355.1
    applied where mother’s testimony that she did not know or have any reason
    to know of her child’s abuse was “completely beside the point” to disproving
    the allegations in the petition]; In re Richard H. (1991) 
    234 Cal.App.3d 1351
    ,
    1363 [expert testimony indicating that child’s injuries were nonaccidental
    established a section 355.1 presumption, which was not rebutted by the
    parents].)
    However, even without applying the statutory presumption, we
    conclude there is substantial evidence in the record to support the juvenile
    18
    court’s jurisdictional findings.6 Although the court found Dr. Robbins and
    Dr. Tawansy to be qualified experts in pediatric ophthalmology, it concluded
    that Dr. Nienow provided the most persuasive testimony on the issue of
    abuse. Dr. Nienow, who the juvenile court certified as an expert in child
    abuse pediatrics, reported that SCHs were extraordinarily rare in normal,
    healthy infants, occurring in only 0.5 percent of that population. She
    testified that in the most recent study conducted on infants presenting with
    SCHs, 97 percent of the SCHs were found to be related to nonaccidental
    trauma. She also explained that other causes unrelated to abuse had been
    ruled out, as the twins presented with no symptoms of upper respiratory
    illness, no history of illness or underlying medical condition, and no history of
    accidental trauma was provided by the parents. Dr. Nienow further testified
    that of the 1,500 child abuse cases she evaluates each year, she determined
    child abuse was the cause of the child’s condition in only 50 percent of those
    cases.
    Dr. Nienow’s conclusion that abuse was the most likely explanation for
    the twins’ injuries was not an isolated opinion, as numerous other doctors
    shared her concerns that the twins’ injuries were inflicted intentionally. For
    instance, Dr. Nienow’s opinion was peer-reviewed twice by seven other child
    abuse pediatricians, all of whom agreed with Dr. Nienow that abuse was the
    most likely explanation. The twins’ primary care provider also stated that
    the circumstances of the twins’ injuries were concerning for abuse. And even
    before Dr. Nienow became involved in the case, the emergency room
    physician who examined Z.N. suspected nonaccidental trauma.
    6     The juvenile court expressly noted that, even if the presumption was
    rebutted, it would have still found the children’s petitions true by a
    preponderance of the evidence.
    19
    Further, although Dr. Robbins differed with Dr. Nienow’s ultimate
    findings, she agreed with Dr. Nienow’s opinion in significant respects. For
    instance, she conceded it was “odd” both twins had the same injury absent
    any underlying conditions. Additionally, it was her opinion that trauma,
    such as a finger poke, is the most common cause of an SCH, while SCHs
    caused by infections are much rarer. Even though Dr. Robbins believed that
    the most common cause of an isolated SCH was accidental trauma, she
    admitted SCHs could constitute a sentinel injury, and that nonaccidental
    trauma could still be considered as a potential cause in this instance.
    The parents raise various contentions to challenge the juvenile court’s
    reliance on Dr. Nienow’s testimony, asserting that the testimony provided by
    their respective experts should have been given greater weight. For example,
    they contend that Dr. Nienow’s opinion was unpersuasive because she is not
    an ophthalmologist. They also challenge the validity of the reports Dr.
    Nienow relied on in formulating her opinion. But these challenges overlook
    the governing standard of review, as we do not reweigh the credibility of
    witnesses or the evidence and we are required to affirm the orders even if
    other evidence supports a contrary finding. (See Casey D., supra, 70
    Cal.App.4th at pp. 52−53 [Under the substantial evidence standard, “[w]e
    have no power to judge the effect or value of the evidence, to weigh the
    evidence, to consider the credibility of witnesses or to resolve conflicts in the
    evidence or the reasonable inferences which may be drawn from that
    evidence.”].)
    The juvenile court was entitled to discount the testimony provided by
    Dr. Robbins and Dr. Tawansy and find that Dr. Nienow’s conclusions were
    the only reasonable explanation of what caused the twins’ injuries.
    Moreover, the court reasonably questioned the veracity of Dr. Tawansy’s
    20
    testimony; he made a diagnosis of a viral infection in the twins based on
    pictures and blood tests. He never personally examined the twins, and the
    court correctly noted that none of the treating doctors noted any viral
    infections. The court was permitted to rely on the totality of this evidence in
    determining the probative value of Dr. Tawansy’s testimony, and we lack the
    authority to supplant the court’s credibility determinations with our own. (In
    re Cole Y. (2015) 
    233 Cal.App.4th 1444
    , 1451−1452.)
    We are similarly unpersuaded by the parents’ contentions that the
    juvenile court’s section 300, subdivision (a) findings are legally flawed. They
    assert, for instance, that the court’s finding that the twins’ injuries were
    “sentinel” and therefore relatively minor demonstrates that the twins did not
    fall within the definition of section 300, subdivision (a). Under that
    subdivision, “a court may find there is a substantial risk of serious future
    injury based on the manner in which a less serious injury was inflicted, a
    history of repeated inflictions of injuries on the child or the child’s siblings, or
    a combination of these and other actions by the parent or guardian that
    indicate the child is at risk of serious physical harm.” (§ 300, subd. (a).)
    Even though the court found the injuries were sentinel, it was appropriately
    concerned that both twins presented with the same injury. The
    circumstances of Za.N. and Z.N.’s injuries therefore fell directly within the
    definition of section 300, subdivision (a), as there was a “history of repeated
    inflictions of injuries on the child or the child’s siblings[.]” (Italics added.)
    Contrary to the parents’ contentions, there were additional factors in
    this case indicating that the twins were vulnerable to suffering from future,
    more serious abuse, which provides further support for sustaining the
    petitions under section 300, subdivision (a). For instance, it is undisputed
    that the twins’ injuries likely occurred while under their parents’ supervision.
    21
    According to Dr. Robbins and Dr. Nienow, the twins’ SCHs would have been
    visible within the first 24 hours, and the twins were in the parents’ exclusive
    care during the 24 hours leading up to the discovery of the injuries. While
    Dr. Robbins suggested an SCH could be caused by an older sibling
    accidentally, both parents maintained that K.N. was never left alone with the
    twins. Dr. Nienow also provided uncontroverted testimony that premature
    infants generally are more susceptible to abuse.
    The parents also focus on the lack of a definitive cause for the twins’
    injuries, suggesting that such circumstances are insufficient for a
    jurisdictional finding under section 300, subdivision (a). However, appellate
    courts have determined that allegations under section 300 may be sustained
    even if the cause of the child’s injuries is unknown. (See, e.g., In re A.S.
    (2011) 
    202 Cal.App.4th 237
    , 245−246 (In re A.S.) [where the parents could not
    be ruled out as perpetrators for the child’s injuries, a finding of jurisdiction
    under section 300, subdivision (b), was proper], disapproved of on other
    grounds by Conservatorship of O.B. (2020) 
    9 Cal.5th 989
    ; In re Christina T.
    (1986) 
    184 Cal.App.3d 630
    , 640 [jurisdiction under section 300, subdivisions
    (a) and (d), was supported when it could not be ascertained whether the
    father or mother’s boyfriend sexually abused the child]; In re E.H. (2003) 
    108 Cal.App.4th 659
    , 670 [“where there is no identifiable perpetrator, only a cast
    of suspects, jurisdiction under subdivision (e) is not automatically ruled
    out”].) As the court in In re A.S. explained: “ ‘Unlike criminal proceedings,
    where establishing the identity of the perpetrator is paramount, the purpose
    of dependency proceedings [is] to fashion appropriate orders in the best
    interest of the child. . . .’ [Citation.] If a perpetrator’s identity must be
    conclusively established, ‘a family could stonewall the [social services
    department] and its social workers concerning the origin of a child’s injuries
    22
    and escape a jurisdictional finding. . . .’ [Citation.] The prerequisite of a
    conclusive identification could lead to absurd results: the potential return of
    a seriously injured child to an unidentified perpetrator. The purpose of
    dependency law ‘is to provide maximum safety and protection’ for currently
    abused and neglected children and to ensure the safety of children at risk of
    harm.” (In re A.S., at pp. 245–246.)
    At the time of the contested adjudication, the parents could not be
    ruled out as the perpetrators of the twins’ injuries. As explained ante, the
    twins were under their parents’ exclusive care when the injuries presented,
    and multiple medical professionals agreed that the absence of any
    explanation for the injuries suggested nonaccidental trauma. Such evidence
    supports a reasonable inference that the twins were at a substantial risk of
    serious physical harm and was sufficient to sustain the jurisdictional findings
    under section 300, subdivision (a). (See In re D.P., supra, 225 Cal.App.4th at
    p. 903 [“The undisputed evidence of nonaccidental trauma and mother’s
    failure to explain how [her minor son] was injured in her care constituted
    substantial evidence that mother was responsible for inflicting these injuries
    on [the minor].”].)
    The parents also highlight statements made by the juvenile court when
    ruling on disposition, which they argue could suggest there was no longer a
    risk of future harm. In this section of its ruling, the court noted that the
    parents were hardworking, loved their children, and that having “a really bad
    moment . . . doesn’t make you a really bad person.” The court also stated that
    although the abuse may have occurred in “a moment of weakness,” this did
    not necessarily mean it would happen again. The parents deduce that these
    dispositional findings indicated there was no substantial danger to the
    children’s well-being and were therefore inconsistent with the court’s
    23
    jurisdictional findings that the children were at substantial risk of serious
    harm.
    None of the statements the parents emphasize, however, are
    necessarily inconsistent with the juvenile court’s jurisdictional findings.
    While jurisdictional findings require only a preponderance of the evidence
    (§§ 300, 355, subd. (a)), a dependent child may not be taken from the physical
    custody of the parent under section 361 at the dispositional stage unless the
    court finds there is clear and convincing evidence of a substantial danger to
    the child’s well-being if returned home, and there are no reasonable means to
    protect the child’s physical health without removing the child (§ 361, subd.
    (c)(1)). The court in this case expressly found that although the evidence was
    sufficient to establish jurisdiction by a preponderance of the evidence, it did
    not find clear and convincing evidence to justify the children’s continued
    removal from the home. Rather than establishing an inconsistency, these
    findings reflect the court’s compliance with the heightened burden of proof
    required for establishing disposition relative to jurisdiction.
    As we have explained, there is substantial evidence in the record to
    support the juvenile court’s jurisdictional findings under section 300,
    subdivision (a). Correspondingly, the court’s assumption of jurisdiction over
    K.N. pursuant to section 300, subdivision (j) is also supported. Under section
    300, subdivision (j), “[t]he court shall consider the circumstances surrounding
    the abuse or neglect of the sibling, the age and gender of each child, the
    nature of the abuse or neglect of the sibling, the mental condition of the
    parent or guardian, and any other factors the court considers probative in
    determining whether there is substantial risk to the child.” In this case, the
    Agency was unable to confirm K.N.’s allegation that Father hit her in the
    face. However, “[t]he juvenile court need not wait until a child is seriously
    24
    injured to assume jurisdiction if there is evidence that the child is at risk of
    future harm from the parent’s negligent conduct.” (In re Yolanda L. (2017) 
    7 Cal.App.5th 987
    , 993.) In the absence of any confirmed injuries to K.N., the
    court could still reasonably conclude that the unexplained injuries to K.N.’s
    siblings placed her at a substantial risk. K.N. was similarly situated to the
    twins given her young age, complete reliance on her parents for care, and her
    own developmental needs. Further, K.N.’s difficulties communicating with
    the social workers throughout these proceedings indicated she may be unable
    to report abuse. Thus, the similarities in the circumstances of these siblings
    are sufficient to sustain the jurisdictional allegations in K.N.’s petition.
    B.    The Juvenile Court Did Not Abuse Its Discretion in Ordering Family
    Maintenance Services
    After the juvenile court makes a true finding at the jurisdictional phase
    of a dependency case, the court must then consider whether a minor should
    be declared a dependent and whether he or she would be at substantial risk
    of harm if not removed from the parent’s care. (§§ 358, subd. (a), 360, 361;
    see In re Austin P. (2004) 
    118 Cal.App.4th 1124
    , 1129.) In general, “ ‘[t]he
    juvenile court has broad discretion to determine what would best serve and
    protect the child’s interest and to fashion a dispositional order in accordance
    with this discretion.’ ” (In re Neil D. (2007) 
    155 Cal.App.4th 219
    , 225.) The
    juvenile court’s order “ ‘will not be reversed absent a clear abuse of
    discretion.’ ” (Ibid.)
    In challenging the dispositional orders, the parents assert that the
    juvenile court impliedly found that the abuse “was a one-time event, and that
    it would not happen again.” They highlight statements the court made
    complimenting the parents for being hardworking and loving their children,
    and the court’s indication that there was not “necessarily a propensity” for
    further abuse. Based on these comments, combined with the court’s decision
    25
    to return the children to the parents’ care, the parents assert that their
    continued supervision under a court-ordered family maintenance plan is
    arbitrary.
    The parents’ challenge to the juvenile court’s dispositional findings,
    however, takes the court’s statements out of context. The court did not find
    that the abuse was a “one-time event.” Rather, it was optimistic that the
    children could safely return to the parents’ care but believed that a family
    maintenance plan was necessary to ensure there were no further instances of
    abuse. The court also cited the appropriate legal standards throughout its
    decision, and as explained previously, the dispositional and jurisdictional
    findings reflected the Agency’s differing burdens of proof. (§§ 300, 355, subd.
    (a), 361, subd. (c)(1).) Thus, sustaining the jurisdictional allegations while
    also returning the children to the parents’ care was neither arbitrary nor
    inherently inconsistent.
    The specific aspects of the family maintenance plan further
    demonstrate that the juvenile court acted within its discretion when it made
    its dispositional orders. For instance, the family maintenance plan included
    the requirement that two adults be present in the home with the children at
    all times, and that the parents attend child abuse classes. Both provisions
    specifically addressed concerns the Agency raised regarding Father’s stress
    level as the sole caregiver for the children while Mother is at work, and the
    parents’ refusal to attend child abuses classes unless it was court-ordered.
    Overall, the court was entitled to fashion its dispositional orders in the
    manner it determined would serve the children’s best interests, and requiring
    the parents to comply with a family maintenance plan does not constitute an
    abuse of discretion under the circumstances of this case. (In re Nada R.
    (2001) 
    89 Cal.App.4th 1166
    , 1179.)
    26
    C.      The Juvenile Court Was Not Biased Against the Parents
    The Due Process Clause “ ‘entitles a person to an impartial and
    disinterested tribunal in both civil and criminal cases.’ ” (Brown v. American
    Bicycle Group, LLC (2014) 
    224 Cal.App.4th 665
    , 673.) That right extends not
    only to criminal defendants but to civil litigants as well. (People v. Scott
    (1997) 
    15 Cal.4th 1188
    , 1206.) However, as the California Supreme Court
    has explained, “[m]ere expressions of opinion by a trial judge based on actual
    observation of the witnesses and evidence in the courtroom do not
    demonstrate a bias.” (People v. Guerra (2006) 
    37 Cal.4th 1067
    , 1111
    (Guerra), overruled on another point in People v. Rundle (2008) 
    43 Cal.4th 76
    ,
    151.)
    On appeal, our task is to “assess whether any judicial misconduct or
    bias was so prejudicial that it deprived [the appellant] of ‘ “a fair, as opposed
    to a perfect, trial.” ’ ” (Guerra, supra, 37 Cal.4th at p. 1112.) This standard is
    “an objective one,” and it requires a showing of bias on the part of the trial
    judge that is so great as to become “ ‘ “constitutionally intolerable.” ’ ” (People
    v. Freeman (2010) 
    47 Cal.4th 993
    , 1001.)
    The parents’ assertion that the juvenile court was biased against them
    relies on comments the judge made indicating his familiarity with Dr.
    Nienow and one of the social workers who testified in this matter. The
    parents contend that rather than basing its credibility determinations on the
    testimony presented at trial, the court had predetermined the credibility of
    these witnesses.
    We perceive no judicial bias in our review of the record. For instance,
    in finding that Dr. Nienow was credible, the juvenile court expressly referred
    to the testimony Dr. Nienow provided in this matter to support the present
    petitions. The court was particularly persuaded by her testimony that she
    27
    finds child abuse in only about half of the cases she reviews. Similarly, the
    court made a positive credibility finding of the social worker based on her
    “work product,” indicating that the court had relied on the quality of the
    reports the social worker provided in these proceedings. Thus, although
    there were passing references to the court’s prior cases that involved these
    witnesses, the credibility determinations were rooted in the evidence
    presented in this matter.7
    The record is otherwise replete with examples showing that the
    juvenile court treated the parties fairly and even-handedly, and with
    empathy. For instance, the court rejected the Agency’s request for out-of-
    home detention, instead allowing the children to return to the parents’ care.
    In making these dispositional findings, the court described the parents as
    “very good people,” “hardworking,” and that they appeared to love their
    children⎯compliments the parents have expressly recognized in this appeal.
    Even though the court ultimately found the Agency’s evidence more
    persuasive as to the jurisdictional allegations, the court also found Mother’s
    expert, Dr. Robbins, to be “a very highly qualified witness” with “very
    impressive credentials” in her own right. (Cf. Guerra, 
    supra, 37
     Cal.4th at
    p. 112 [“a trial court’s numerous rulings against a party—even when
    erroneous—do not establish a charge of judicial bias”].) This record, on the
    whole, does not support the parents’ claims of judicial bias.
    7      We note that the juvenile court’s stray remarks regarding its prior
    experiences with these witnesses were unnecessary to the court’s ultimate
    findings in this case, and thus it may have been preferrable for the court to
    refrain from such commentary. Nevertheless, “[t]he role of a reviewing court
    ‘is not to determine whether the trial judge’s conduct left something to be
    desired, or even whether some comments would have been better left unsaid.’
    [Citation].” (People v. Harris (2005) 
    37 Cal.4th 310
    , 347.)
    28
    DISPOSITION
    The orders of the juvenile court are affirmed.
    DO, J.
    WE CONCUR:
    IRION, Acting P. J.
    GUERRERO, J.
    29