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Appendix A

Sacramento Appropriately Responded to the Discovery of Elevated Levels of Lead in Drinking Water Sources on Its Campus

As we mention in the Introduction, in March 2016, two Sacramento faculty members began a classroom project that eventually identified high lead levels in a number of campus drinking‑water sources. The CSU employees union and members of the Legislature indicated that Sacramento waited 10 months to inform the campus community about the high levels of lead. However, our assessment found that the campus acted appropriately and promptly. Specifically, after testing 42 drinking water sources beginning in March 2016, which continued through that summer, the two faculty members identified one drinking source with elevated levels of lead that, nonetheless, fell below the Environmental Protection Agency (EPA) action level of 15 parts per billion (ppb). In August 2016, the faculty members notified campus officials, who shut off the fountain despite the fact that the lead levels were below 15 ppb and therefore did not require the campus to take any action. In January 2017, at the request of the campus, the faculty members completed a second round of testing that included about 450 drinking water sources and identified 27 sources that had levels of lead above the EPA’s action level. Upon being notified, campus officials immediately closed these drinking water sources. The campus then consulted with city and county officials and, less than two weeks after closing the 27 water sources, notified the campus community of the high levels of lead.

The campus also hired a third‑party consultant to conduct additional tests of drinking water on campus. Of the 782 sources that the contractor tested, 43 tested over 15 ppb, and Sacramento closed these sources down immediately in May 2017. By July 2017, Sacramento officials had replaced all drinking water sources that had been identified as having high levels of lead. In January 2018, the campus announced that it was in the process of adding labels containing bar codes to drinking fountains on campus. The labels allow the campus community to scan the code and view the most recent test results for that specific drinking fountain. In that same month, after aggregating the data, campus officials concluded that no drinking water sources were now above the EPA action level and that 94 percent of the drinking water sources were at or below the more stringent Food and Drug Administration’s guidelines for lead in bottled water. Table A shows the timeline of events related to the discovery of lead in the campus drinking water supply, including the campus’s response.

Table A
Timeline of Key Events Related to Sacramento’s Response to the Discovery of Lead in Campus Drinking Water Sources

Date	Summary of Event	Sacramento’s Response

March 2016	Two professors from Sacramento began a project in which they and two students sampled 42 drinking water sources at eight buildings on campus. This testing continued through the summer.
August 12, 2016	The professors first shared with Sacramento’s EH&S office the findings from their first phase of the project. None of their results were above the EPA’s action level of 15 ppb. However, one fountain had a lead level of 8.86 ppb, which is below the EPA action level but above the recommended level in bottled water according to the Food and Drug Administration (FDA). The professors shared with the campus the results from an independent contractor that verified their results.	Out of caution, the campus shut off the fountain with a lead level of 8.86 ppb.
November 17, 2016 and November 18, 2016	Staff notified the campus president that the EH&S office had conducted additional testing in October 2016 at the Children’s Center, a child‑care program on campus. The EH&S office reported that it collected 18 samples and that two samples from drinking fountains tested positive for lead, but below the EPA action level.	According to campus officials, the Children’s Center staff immediately shut off the fountains even though neither water source tested above the EPA action level.
January 6, 2017 through January 12, 2017	The campus requested, and provided funding for, the professors and their students to conduct a second round of testing. The professors and students tested about 450 water sources, including sinks, drinking fountains, faucets, filtered refrigerator spouts, and bottle‑filling stations across campus.
January 13, 2017	Staff notified the campus president that the additional testing identified 27 drinking water sources with lead levels above the EPA action level of 15 ppb.	According to Sacramento officials, staff immediately shut down all drinking water sources that tested above 15 ppb.
January 17, 2017 through January 24, 2017		Sacramento officials stated that the campus president met with staff from Risk Management Services, one of the professors, and the EH&S office. He also consulted with the county of Sacramento and the city of Sacramento about the steps the campus should take next. The campus kept all drinking water sources over 15 ppb shut down and the campus community was not notified until after consulting with the city and county.
January 25, 2017		The Office of the Vice President for Administration notified the campus community about the results of the additional testing, explaining that campus staff had turned off the identified sources of drinking water that contained elevated levels of lead and that testing would continue, since all sources of drinking water on campus had not yet been sampled. The office also announced that bottled water was available for the campus community at designated locations.
January 26, 2017		The campus hosted a town hall meeting in which a doctor of occupational medicine and a public health officer from the county of Sacramento answered questions.
February 7, 2017		Campus officials posted an update on Sacramento’s website explaining that the new interim senior director for risk management services/chief risk officer had been meeting with licensed health and safety consultants to formulate an action plan to address the issues that the water quality testing identified. Further, campus officials stated that in the meantime, it had shut off all drinking water sources.
February 21, 2017		The Office of the Vice President for Administration updated the campus community by stating that the campus had completed testing of all drinking and food‑ preparation water sources at all campus dining establishments and that all these sources tested below the EPA action level. California Laboratory Services, a third‑party consulting firm, performed the testing and analysis.
February 28, 2017		The Office of the Vice President for Administration updated the campus community by explaining that the campus had hired California Industrial Hygiene Services Inc. (CIH) to perform additional testing and lab analysis of drinking water sources, which would commence in early March and take several weeks.
April 14, 2017		The Office of the Vice President for Administration notified the campus community that the testing of drinking water sources was taking longer than previously anticipated and that the campus expected the testing to be complete by early May.
April 27, 2017		The Office of the Vice President for Administration notified the campus community that campus officials anticipated being able to share the results of the testing and the campus’s action plan with the community in the next two weeks and that the campus would be scheduling a campus forum for those who had questions after reviewing the documents. The announcement also provided an update on the results of the testing to date.
May 8, 2017	The results of further testing identified that 43 of 782 drinking water sources had lead levels above the EPA action level.	The Office of the Vice President for Administration shared with the campus community the completed testing results. The campus immediately closed the 43 water sources that had over 15 ppb.
May 15, 2017		The campus hosted an open forum with a public health officer from Sacramento County to discuss the testing results in greater detail.
May through July 2017		The EH&S office replaced the fixtures that were above 15 ppb.
August 23, 2017	The professor continued to sample drinking water sources and found three drinking water sources with lead above the EPA action level.	The Office of the Vice President for Administration sent an announcement to the campus community notifying them that over the summer, a professor and his students collected 300 water samples across campus, and their preliminary results indicated that three drinking water sources contained levels of lead above 15 ppb. Campus officials stated that the campus’s Facilities Management shut off the three drinking water sources. The campus announced it would contract with a third‑party consultant to test the drinking water sources identified by the professor.
September 29, 2017	CIH reported that the water sources the professor identified as containing levels of lead above the EPA action level were below the EPA action level. The difference in the results were due to differing testing methods. CIH used standard EPA protocol.
January 10, 2018		The campus aggregated the data generated by water testing CIH performed. The data demonstrated that no drinking water sources were above the EPA action level and 94 percent of the drinking water sources were at or below FDA guidelines for bottled water.
January 16, 2018		The campus announced that a water database was available to the public and described a coding system that Risk Management Services was in the process of installing on the drinking fountains. The coding system allows the public to scan codes on labels placed on the drinking fountain to confirm the drinking water sources’ most recent test results.
January 24, 2018		Risk Management Services added labels to nearly all of the drinking water fountains on campus.

Source: California State Auditor’s review of available documentation provided by campus officials and interviews with key staff.

Appendix B

Survey of Instructional Support Assistants and Technicians from all California State University Campuses

The Audit Committee asked us to survey laboratory instructional support assistants and technicians (support technicians) to obtain a general overview of the health and safety climates at the campuses and to receive staff perspective on laboratory conditions and compliance with existing laws and regulations. We received contact information from the Chancellor’s Office for support technicians at all CSU campuses with the exception of California State University Maritime Academy (Maritime). The list with contact information that the Chancellor’s Office provided noted that Maritime did not have any support technicians with exposure to hazardous materials, which we confirmed with Maritime’s director of risk management. The Chancellor’s Office identified 447 support technicians at the remaining 22 campuses whose work exposes them to hazardous materials. Of these 447 individuals, 244—representing all 22 campuses—completed our survey. Figure B highlights key statistics from the 244 completed surveys.

Figure B
A Snapshot of Our Survey of Support Technicians

Figure B, an info-graphic with statistics reflecting the survey responses of 244 instruction support technicians throughout the California State University system. Included among the statistics are that 13 percent of the respondents stated that the campus does not provide a healthy and safe work environment, and 18 percent believe campus management has not emphasized the importance of health and safety when using hazardous chemicals.

Source: California State Auditor’s analysis of responses to a health and safety survey it administered to CSU support technicians.

*Based on responses from all 244 respondents.

^†Based on responses from 193 support technicians whom the Chancellor’s Office indicated worked in biology, chemistry, engineering, physics, and art departments, or whom the Chancellor’s Office indicated worked in natural sciences. We present the results for these specific departments because these are the departments on which we focused our audit work.

Overall, the results of our survey indicate that a significant number of those who responded believe that the campuses could do more to establish health and safety as a priority. As Table B.1 shows, 31 respondents (13 percent) believe that their campuses do not provide healthy and safe work environments. In fact, some individuals commented that they believe their work environments have negatively affected their health. In addition, some respondents stated that their campuses have been slow to respond to or have not followed up on complaints they have made regarding what they believed were hazardous or unsafe working conditions.

Table B.1
Responses to Key Questions of General Applicability

	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics		Other
Is your office located inside, or does it include an adjoining door or window to a chemical stockroom?
	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	89	36%	4	22%	33	38%	31	65%	2	17%	0	0%	6	32%	13	25%
No	155	64%	14	78%	54	62%	17	35%	10	83%	9	100%	13	68%	38	75%

Do you believe your office has adequate ventilation to prevent any harm from the nearby chemicals?†
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics		Other
	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	58	65%	4	100%	20	61%	19	61%	2	100%	0	–	5	83%	8	62%
No	31	35%	0	0%	13	39%	12	39%	0	0%	0	–	1	17%	5	38%

Does the campus have written procedures for instructional support assistants and instructional support technicians to follow in response to an incident (For example, an injury or chemical spill in a chemical stockroom or laboratory area)?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics		Other
	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	167	69%	13	72%	64	74%	32	67%	5	42%	4	44%	14	74%	35	69%
No	20	8%	0	0%	7	8%	9	19%	1	8%	1	12%	1	5%	1	2%
I do not know	57	23%	5	28%	16	18%	7	14%	6	50%	4	44%	4	21%	15	29%

Does the campus define in writing your roles and responsibilities regarding the safety and well‑being of students and employees?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics		Other
	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	138	57%	11	61%	52	60%	30	62%	4	34%	2	22%	13	69%	26	51%
No	39	16%	2	11%	13	15%	11	23%	1	8%	3	33%	1	5%	8	16%
I don’t know	67	27%	5	28%	22	25%	7	15%	7	58%	4	45%	5	26%	17	33%

Do you perceive any impediments to reporting concerns about hazardous or unsafe working conditions on your campus?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics		Other
	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	28	11%	1	6%	9	10%	10	21%	1	8%	1	11%	2	11%	4	8%
No	216	89%	17	94%	78	90%	38	79%	11	92%	8	89%	17	89%	47	92%

Has campus management emphasized the importance of health and safety when using hazardous chemicals?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics		Other
	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	199	82%	15	83%	74	85%	35	73%	11	92%	5	56%	15	79%	44	86%
No	45	18%	3	17%	13	15%	13	27%	1	8%	4	44%	4	21%	7	14%

Do you feel the campus provides employees with a healthy and safe work environment when working with or near chemicals or other hazardous materials?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics		Other
	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	213	87%	15	83%	80	92%	38	79%	12	100%	7	78%	15	79%	46	90%
No	31	13%	3	17%	7	8%	10	21%	0	0%	2	22%	4	21%	5	10%

Source: California State Auditor’s analysis of records from work order systems provided by the four campuses we reviewed.

Note: The questions shown in the table are not specific to laboratory and chemical stockroom environments. Therefore, the information presented in this table includes responses from all 244 respondents.

*Includes respondents who, according to the list we received from the Chancellor’s office, work in natural sciences but did not specify a department.

^†Responses to this question are only shown for the 89 respondents who indicated their office was located inside or included an adjoining door or window to a chemical stockroom.

Of the 244 respondents, we identified 193 who work in the art, biology, chemistry, engineering, and physics departments at their campuses, as well as others who work in one of the natural sciences, but did not specify which one. For certain questions, we focused on responses from these 193 individuals because our audit work focuses on these departments. According to responses and comments from those 193 support technicians, some believe that their campus has not always provided them with enough resources to ensure their health and safety. For example, one respondent commented that campus officials provided one kit for cleaning chemical spills (spill kit) to her department after she asked for multiple kits on several occasions. According to this support technician, campus officials told the support technician that the department should provide the rest of the spill kits. However, she stated that the department had not bought the additional kits and that some labs still did not have spill kits. Further, 36 percent of the 193 support technicians who indicated they received laboratory safety training stated that the training they had received was either missing important information or ineffective. One support technician explained that the campus does not provide its support technicians the time to attend safety trainings. In fact, she commented that the last time she received safety training was about 20 years ago. She explained that the campus has offered other safety trainings since then, but the trainings have conflicted with her schedule. She noted there were no consequences for not completing safety training, unlike trainings on topics such as sexual harassment. Table B.2 presents the responses to key questions specific to the laboratory and chemical stockroom environments that we specifically asked those working in such environments.

Table B.2
Responses to Selected Questions Specific to Laboratory and Chemical Stockroom Environments

	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics

Did the campus provide you training on laboratory health and safety protocols before you began work?
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	124	64%	9	50%	64	74%	30	63%	4	33%	4	44%	13	68%
No	69	36%	9	50%	23	26%	18	37%	8	67%	5	56%	6	32%

How often does the campus provide you training on laboratory health and safety?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Have never received training	14	7%	4	22%	2	2%	3	6%	3	25%	0	0%	2	11%
More than once per year	52	27%	3	17%	26	30%	18	38%	1	8%	2	22%	2	11%
Once per year	90	47%	9	50%	37	42%	20	42%	5	42%	5	56%	14	73%
Once every two years	7	4%	0	0%	4	5%	2	4%	0	0%	1	11%	0	0%
Less than once every two years	30	15%	2	11%	18	21%	5	10%	3	25%	1	11%	1	5%

How would you rate the training provided to you?†
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Effective	114	64%	9	64%	55	65%	30	67%	6	67%	3	33%	11	64%
Adequate but missing some important information	56	31%	4	29%	26	31%	14	31%	3	33%	6	67%	3	18%
Not effective	9	5%	1	7%	4	4%	1	2%	0	0%	0	0%	3	18%

Does campus management seek and include your input when assessing risks to employee health and safety in chemical stockroom or laboratory areas?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	105	54%	12	67%	43	49%	25	52%	10	83%	4	44%	11	58%
No	88	46%	6	33%	44	51%	23	48%	2	17%	5	56%	8	42%

Does the campus provide you with necessary personal protective equipment (e.g. lab coats, gloves, eye protection, ear protection, etc.) in a timely manner to ensure your personal health and safety?‡
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	173	91%	16	89%	81	93%	43	90%	8	80%	8	89%	17	94%
No	17	9%	2	11%	6	7%	5	10%	2	20%	1	11%	1	6%
NA	3	–	0	–	0	–	0	–	2	–	0	–	1	–

Do the campus’s primary chemical storage areas (chemical stockrooms) include the requisite engineering controls (e.g. supportive storage shelving, air filtration system, fume hoods, etc.) to provide a safe environment?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	112	77%	9	75%	49	75%	35	76%	3	75%	7	78%	9	90%
No	34	23%	3	25%	16	25%	11	24%	1	25%	2	22%	1	10%
NA§	47	–	6	–	22	–	2	–	8	–	0	–	9	–

Do the campus’s laboratory areas include requisite engineering controls (e.g. supportive storage shelving, air filtration system, fume hoods, etc.) to provide a safe environment?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	141	85%	11	73%	66	87%	40	85%	7	100%	7	78%	10	91%
No	24	15%	4	27%	10	13%	7	15%	0	0%	2	22%	1	9%
NA§	28	–	3	–	11	–	1	–	5	–	0	–	8	–

Do the campus’s chemical stockrooms include the requisite emergency safeguards (e.g. eyewash stations, showers, fire suppression system, etc.) to provide a safe environment?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	138	90%	10	83%	66	96%	41	89%	4	67%	6	75%	11	92%
No	15	10%	2	17%	3	4%	5	11%	2	33%	2	25%	1	8%
NA§	40	–	6	–	18	–	2	–	6	–	1	–	7	–

Do all laboratory areas include the requisite emergency safeguards (e.g. eyewash stations, showers, fire suppression system, etc.) to provide a safe environment?
	All Departments		Art		Biology		Chemistry		Engineering		Natural Sciences*		Physics
Possible Answers	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage	Responses	Percentage
Yes	148	85%	13	93%	65	80%	44	92%	6	86%	7	78%	13	87%
No	26	15%	1	7%	16	20%	4	8%	1	14%	2	22%	2	13%
NA§	19	–	4	–	6	–	0	–	5	–	0	–	4	–

Source: California State Auditor’s analysis of responses to a health and safety survey it administered to CSU support technicians.

Note: Based on responses from 193 support technicians whom the Chancellor’s Office indicated worked in Biology, Chemistry, Engineering, Physics, and Art departments, or who the Chancellor’s Office indicated worked in Natural Sciences. We present the results for these specific departments because these are the departments in which we focused our audit work.

*Includes individuals who, according to the list we received from the Chancellor’s office, work in Natural Sciences but did not a specify a department.

^†Responses to this question are only shown for the 179 respondents who indicated they had received training on health and safety.

^‡Eleven respondents selected “No” as their response to this question, but either indicated their departments provides them the equipment or commented the campus does provide them with equipment. We have included these individuals’ responses with those that answered “Yes” to this question because all 11 indicated they received personal protective equipment. Further, we categorized three responses as not applicable (NA) because respondents commented the question was not applicable to them or their comments made it unclear whether the question applied to them.

^§Respondents stated the question was not applicable to their work.

Appendix C

Enforcement Actions Taken Against the Campuses We Reviewed

The Audit Committee directed us to determine the enforcement actions for health and safety violations levied over the last five years against the Chancellor’s Office and the four campuses we reviewed and to identify the agencies that issued such actions. We defined enforcement actions as violations for which enforcement agencies levied a monetary penalty against the Chancellor’s Office or one of the four campuses. Enforcement actions can be generated in different ways. For example, Cal/OSHA can issue citations as the result of investigations it conducts of employee complaints or of its targeted inspections. To identify any enforcement actions levied against the Chancellor’s Office and the four campuses, we requested that they each provide us with a list of all enforcement actions for the previous five years. To verify that the information they provided was complete, we asked selected enforcement agencies—such as Cal/OSHA and pertinent county hazardous materials divisions—to provide information about the enforcement actions they took against the Chancellor’s Office and the four campuses. We determined that no agencies took enforcement action against the Chancellor’s Office during the period we reviewed. Agencies took a total of 13 actions against the four campuses during the review period, resulting in total penalties of nearly $48,000. Table C presents the enforcement actions agencies took against the four campuses that resulted in monetary penalties, the issuing agencies, the years of issuance, the penalty amounts, and brief summaries of the violations. We found that each campus had fully addressed all of the enforcement actions we identify in the table.

Table C
Enforcement Actions Levied Against Selected California State University Campuses Between
Fiscal Years 2012–13 and 2016–17
Campus	Issuing Agency	Year Issued	Penalty Amount	Summary of Violation*
Channel Islands	The California Department of Industrial Relations, Division of Occupational Safety and Health (Cal/OSHA)	2012	$18,300	The campus did not: Post a warning sign on an air compressor that could injure employees to warn them that the compressor is automatically controlled and may start at any time. Post the operating rules for an industrial truck. Relieve a hot water pipe of internal pressure before opening or dismantling the pipeline, resulting in a valve opening briefly and spraying an employee with hot water, causing second‑ and third‑degree burns.
Channel Islands		2013	640	The campus did not provide effective training regarding its response to heat illness incidents and prevention, and campus staff did not respond appropriately when employees displayed signs and symptoms of heat illness.
Total penalties against Channel Islands			$18,940
Sacramento	Sacramento County, Environmental Management Department, Environmental Compliance Division	2017	$6,610	The campus did not: Dispose of hazardous waste at an authorized location. Dispose of hazardous waste within the required time. Have its spill prevention plan, which helps to prevent oil spills and control spills when they occur, self‑certified or certified by a professional engineer. Review the spill prevention plan within five years of the last review or certification date. Provide an immediate, verbal report of a release or threatened release of a hazardous material to the Sacramento County Environmental Management Department, Environmental Compliance Division and the California Office of Emergency Services Adequately train employees in the handling and management of hazardous waste to ensure that personnel are able to respond effectively to emergencies.
Total penalties against Sacramento			$6,610
San Diego	County of San Diego Air Pollution Control District (district)	2012	$750	The campus did not report a breakdown in an emergency generator to the district. Additionally, the breakdown caused the generator to run for more than the 52 hours allowed each year for nonemergency purposes.

		2013	1,000	The campus did not notify the district in a timely manner of a possible breakdown of a gas flow meter in a gas turbine engine.
			1,200	The campus installed a sand blast cabinet— which may cause the issuance of air contaminants—without first obtaining the district’s written authorization.
		2014	2,400	The campus did not meet a deadline to input required information into its emissions reporting system.
			1,000	The campus violated an open container regulation by leaving approximately 50 containers of paint containing volatile organic compounds open to dry.
		2015	500	The campus did not provide the district with a timely new notice of a changed start date for a building demolition.
			10,000	The campus installed and operated a gas turbine engine without first submitting an application.
		2017	750	The campus did not conduct periodic maintenance and keep maintenance records in 2015 and 2016 for an emergency generator. The campus also failed to maintain a complete operating log.
Total penalties against San Diego			$17,600
Sonoma	Cal/OSHA	2012	$2,240	The campus did not determine if an employee engaged in leaf blowing gutters was exposed to lead, did not establish and implement a written compliance program before the leaf blowing job, and failed to ensure that all surfaces at the worksite were maintained as free as practicable of lead accumulations.
Sonoma	Cal/OSHA	2017^†	2,400	The campus did not: Determine the quantity of materials that contain or may contain asbestos in various buildings on campus. Post warning signs regarding asbestos at the entrance of mechanical rooms that contain or may contain asbestos. Post warning labels on materials that contain or may contain asbestos. Provide employees performing housekeeping operations in areas that contain or may contain asbestos with annual asbestos awareness training that contained all required elements. Maintain all surfaces as free as practicable of asbestos containing material waste and debris.
Total penalties against Sonoma			$4,640
Total penalties against the four campuses			$47,790

Source: California State Auditor’s analysis of information provided by the four campuses we reviewed, select enforcement agencies, and interviews with relevant staff.

^*We found that all violations in this table have since been resolved by the campuses.

^† Cal/OSHA issued this enforcement action early in fiscal year 2017–18; however, we have included it here because Cal/OSHA conducted associated inspections within fiscal year 2016–17 and because citations in the action were related to another audit objective.

Appendix D

Scope and Methodology

The Audit Committee directed the State Auditor to examine the extent to which the Chancellor’s Office and four selected campuses—Channel Islands, Sacramento, San Diego, and Sonoma—comply with and enforce laws designed to ensure the health and safety of individuals in and around laboratory settings. The Audit Committee requested that we examine nine specific audit objectives to accomplish this task. Table D describes the Audit Committee’s objectives and our methodology for addressing each one. The Audit Committee also directed us to conduct a systemwide survey of certain laboratory employees.

Table D
Audit Objectives and the Methods Used to Address Them

	Audit Objective	Method

1	Review and evaluate the laws, rules, and regulations significant to the audit objectives.	Reviewed relevant laws and regulations.

2	For the four selected CSU campuses, determine whether the campuses have adequately defined roles and responsibilities for employee and student safety by determining the following for each campus:
	a. Whether the campus has a chemical hygiene committee and a joint university safety committee in accordance with state or federal regulations. Also, determine how often these committees meet and whether minutes are taken and made available to employees upon request.	Obtained policies at all four campuses we visited including those established by each campus’s EH&S office. Interviewed relevant staff and reviewed relevant documentation to determine chemical hygiene committee meeting frequency, topics of discussion, and availability of minutes. Interviewed relevant staff and reviewed relevant documentation to determine whether a joint university safety committee exists at the system level and at the four campuses that we visited. Determined the meeting frequency, topics of discussion, and availability of meeting minutes for those committees.
	b. Whether the roles and responsibilities for the chemical hygiene officer, laboratory supervisors, and principal investigators are clearly defined, documented, and readily available to ensure worker safety.	Interviewed relevant staff and reviewed documentation to assess whether the roles and responsibilities for the chemical hygiene officer, laboratory supervisors, and principal investigators are clearly defined, documented, and readily available. We determined that all four campuses clearly defined, documented, and made available the roles and responsibilities of their chemical hygiene officers, laboratory supervisors, and principal investigators.
	c. Whether the campus has a biosafety committee. If not, assess the appropriateness of not having such a committee. c	Reviewed relevant documentation and interviewed relevant staff to determine whether campuses have a biosafety committee. When applicable, we assessed the appropriateness of a campus not having a biosafety committee. We identified the requirement that warrants a campus creating a biosafety committee is the campus receives National Institutes of Health funding, which it uses to conduct nucleic acid research. We found that only San Diego met this requirement and determined that it has a functioning biosafety committee.
	d. Whether the campus has qualified radiation and laser safety officers. If not, assess the appropriateness of not having such officers.	Reviewed relevant laws and regulations to identify the legal requirements to be a qualified radiation or laser safety officer. We determined that there are no specific qualifications required for a radiation safety officer. However, state regulations require California Department of Public Health, the agency that issues radioactive materials licenses, to evaluate the designated radiation safety officer’s training and experience. We determined that there are no specific qualifications required for a laser safety officer. Interviewed relevant staff to determine how each campus assesses whether these officers are qualified. Reviewed supporting documentation to determine if the current radiation and laser safety officers were reasonably qualified. We determined that all four campuses we reviewed have a laser safety officer who has received appropriate training. Having a valid radioactive materials license is an indication that the radiation safety officer specified in the license has adequate training and experience. Moreover, we found that Sacramento, Sonoma, and San Diego have a radiation safety officer who has appropriate training and experience. Channel Islands does not have a radiation safety officer because it does not have a radiation program that requires such a position.

3	For the four selected campuses, determine whether the campuses ensure adequate availability of safety equipment and monitor the proper operating conditions of such equipment. Specifically, determine the following for each selected campus:
	a. The extent to which the campus provides and requires proper personal protective equipment (for example, lab coats, goggles, gloves, face masks, shields, etc.) and engineering controls (for example, air filters, fume hoods, snorkels, etc.). Determine how often the engineering controls are checked to ensure effectiveness and adequacy for current working conditions and the average replacement and repair time for such equipment.	Reviewed state law and regulations regarding personal protective equipment (PPE) and evaluated each campus’s policies addressing these requirements. Reviewed relevant state regulations to determine the frequency with which campuses are required to inspect fume hoods and autoclaves, and we assessed whether each campus’s policies or inspection records addressed these requirements. Interviewed relevant campus officials to determine how each campus evaluates employee and student PPE needs, whether the campus provides PPE, and whether the PPE was readily accessible to the employee. Selected instructors who taught in a laboratory and worked in departments that use chemicals or hazardous materials. Interviewed them to determine whether the campus provided them with PPE. We found that the instructors we selected had adequate access to PPE. Judgmentally selected courses and haphazardly selected students based on whether the campus told us the class required PPE to determine whether they acknowledged the hazards they would encounter in the laboratory. We judgmentally selected five academic locations where hazardous materials could be used at each campus and identified the three most recent inspections of a selection of engineering controls to determine whether the campuses inspected the engineering controls in those rooms as frequently as state regulations require. We obtained relevant data from the campuses to calculate the repair time for the engineering controls in laboratory environments. Among the work orders we reviewed, we did not identify any work orders that reflected only the replacement of an entire engineering control.
	b. Whether appropriate fire extinguishers, suppression systems, eyewash, emergency showers, and other safeguards are readily available, sufficient for current working conditions, and routinely checked to ensure proper operation.	Determined how frequently state law and regulations require campuses to inspect fire extinguishers, eyewash stations, and emergency showers. We judgmentally selected five academic locations where hazardous substances could be used at each campus and identified the three most recent inspections of a selection of safeguards to determine whether the campus inspected the safeguards in these rooms as frequently as state regulations require. We evaluated whether safeguards were readily available to employees and students working in these environments and sufficient for current working conditions.
	c. How often, and to what degree, the campus monitors air quality and checks ventilation systems where chemicals are stored and where technicians are near chemicals (for example, stockrooms, employee offices, classrooms, hallways, storage facilities, etc.). Also, assess the method, the frequency, and the extent to which biosafety hoods and autoclaves are inspected and certified.	Reviewed relevant documentation and interviewed key facilities officials to determine how often and to what extent each campus monitors air quality and checks ventilation systems where chemicals are stored and where technicians are near chemicals. Reviewed campus maintenance records for selected air handler units—integral ventilation system components that regulate and circulate fresh air—in campus science buildings where technicians are near chemicals. Reviewed relevant documentation and interviewed key officials and determined that all four campuses demonstrated at least annual inspections for selected autoclaves. We further determined that Sacramento, San Diego, and Channel Islands could provide evidence of required annual inspections of selected biosafety cabinets. We discuss Sonoma’s biosafety cabinet inspections.

4	For the four selected campuses, determine how each campus’s procedures and practices for proper storage and safety of equipment ensure the following:
	a. Whether the campus adequately maintains controlled chemicals (for example, flammable, acid, poison, gas, corrosives, etc.) with appropriate certifications and permits for every location where chemicals are maintained. Also, assess the adequacy of safeguards put in place to prevent unauthorized access to laboratories and storage locations where chemicals are kept.	Interviewed relevant staff and reviewed relevant documentation to determine whether the campuses had required chemical permits or certifications. Identified the safeguards the campuses use to prevent unauthorized access to laboratories and storage locations where campuses keep chemicals and assessed their adequacy. We determined that all four campuses have either policies or procedures that address the storage of chemicals. In addition, all four campuses have safeguards in place to prevent unauthorized access to chemicals.
	b. Whether the campus has properly labeled radiation sources. Also, determine whether the campus follows appropriate procedures to ensure that employees who access radiation sources are properly monitored in accordance with applicable laws and regulations.	Interviewed relevant staff and reviewed documentation to determine whether the campuses appropriately labeled selected radiation sources and whether they monitored employee exposure to radiation sources. Our testing found no concerns with how campuses labeled radiation sources and also found that campuses monitored employee exposure to radiation sources.

5	For the four selected campuses, assess the adequacy of each campus’s safety program and student and employee access to information and training by determining the following:
5	a. The extent to which employees have access to appropriate information for compliance with California Hazard Communication regulations or other applicable laws, safety data sheets, standard operating procedures, and where this information is located.	Reviewed state law and regulations regarding safety data sheets, and assessed if each campus’s policies addressed these requirements. Reviewed a selection of employees who use hazardous chemicals at each of the four campuses to determine whether they received information for compliance with California Hazard Communication regulations through training. Reviewed the availability of safety data sheets for 10 selected chemicals listed on campus inventories and found that the four campuses made these available to employees. We reviewed the campuses’ chemical plans and determined that they included standard operating procedures.
	b. How and the extent to which the campus provides annual notifications for lead‑based paint, asbestos, and other carcinogens to campus employees and students. Also, assess whether areas containing lead, asbestos, and other carcinogens are properly marked.	Reviewed state law and regulations for required notifications regarding lead‑based paint, asbestos, and other carcinogens, and assessed if each campus’s policies addressed these requirements. Interviewed key staff and reviewed relevant documentation to determine if the campuses provided annual notifications for lead‑based paint, asbestos, and other carcinogens in the last three academic years. We determined that there is no legal requirement for campuses to provide notifications for lead and other carcinogens. Nevertheless, we found that Sonoma and Channel Islands provide information about the location of lead on their campuses, and Channel Islands and San Diego maintain chemical inventories that contain information about carcinogens. To determine whether campuses properly marked areas containing asbestos, we reviewed the signage in up to five mechanical rooms that we judgmentally selected using information provided by the campuses regarding the location of asbestos.
	c. Whether the campus has clearly defined the roles and responsibilities of individuals in charge of campus protocols and training for the cleanup of incidences such as chemical spills, dead rodents, mice contamination, bodily fluids, needles, and syringes. Also, determine how the scope of the training is established.	Interviewed key staff and reviewed relevant documentation to determine the individuals responsible for establishing the protocols and training for cleanup following incidents. Evaluated campus policies and procedures to determine whether they clearly defined the roles and responsibilities for those charged with establishing protocols and trainings for cleanup following incidents. Interviewed key staff and reviewed relevant documentation to determine how the campuses established the scope and frequency of these trainings. We found that the four campuses established the scope based on relevant regulations. Evaluated the adequacy of the frequency of trainings related to the cleanup of chemical spills, bodily fluids, needles, and syringes. We did not identify any training requirements for the cleanup of dead rodents and mice contamination. We determined that all four campuses have clearly defined the roles and responsibilities of individuals in charge of campus protocols and training for such incidents.
	d. Whether the campus has a respiratory protection program and whether the program is designed to adequately protect employees and students.	Identified federal Occupational Safety and Health Administration regulations for respiratory protection programs and assessed if each campus’s policies addressed these requirements. Interviewed key staff about each campus’s respiratory protection program. We determined that all four of the campuses have respiratory protections programs that are designed to adequately protect employees and students.
	e. Whether the campus has a written blood pathogen program and radiation and laser safety program. Also, determine whether the campus has made employees aware of these programs and the extent to which training and competency of employees in these programs is documented.	Reviewed state law and regulations regarding campus blood pathogen programs, radiation safety programs, and laser safety programs, and assessed if each campus’s policies addressed these requirements. Interviewed key staff and reviewed documentation related to each campus’s blood pathogen program, radiation safety program, and laser safety program. Reviewed the annual training records from the last three years to determine if five judgmentally selected employees covered under the respective blood pathogen, radiation safety, and laser safety programs received training. We determined that Sacramento, Sonoma, and San Diego have radiation programs, and we determined from our review of a selection of employee training records that the campuses all document the trainings. Channel Islands does not have a radiation safety program because it does not have radiation sources on campus. Similarly, we found that Sonoma, Channel Islands, and San Diego have laser safety programs, and we determined from our review of a selection of employee training records that the campuses document their training records. Although Sacramento has a laser safety program, it does not currently use the type of laser that warrants employee training.
	f. Whether the campus had adequate policies, protocols, and practices for training and supervising students on the hazards of the laboratory. Also, determine whether students and employees are provided safety training prior to working in the laboratories and are adequately supervised while working in teaching and research labs.	Reviewed state law and regulations regarding student and employee training, and assessed if each campus’s policies addressed these requirements. Interviewed key staff and reviewed documentation to determine how the campuses train students and employees on the hazards of the laboratory and to determine whether employees are evaluated on their supervision of students. Reviewed training records for five judgmentally selected students and five judgmentally selected employees to determine if they received training in compliance with campus policies for the past three years. Evaluated two incident reports or near‑accident reports from each campus to determine whether students were adequately supervised and if those charged with supervision responded to these incidents appropriately. Based on the work we performed, we did not identify anything indicating the students were not adequately supervised.
	g. Whether the campus has an ongoing training for quarantine procedures in the event of an outbreak of disease on campus.	Interviewed key staff and reviewed documentation to determine whether each campus has an ongoing training for quarantine procedures in the event of an outbreak of disease on campus. There are no requirements for a campus to have these procedures campuswide; however, Health Services departments at each campus have quarantine procedures.

6	For the four selected campuses and the Chancellor’s Office, assess the monitoring of compliance with health and safety laws, regulations, policies, and procedures by determining the following:
	a. Whether the campus performs self‑audits in teaching and research laboratories that use potential hazardous chemicals and equipment. If the campus does not perform self‑audits, assess its reasons. If the campus performs self‑audits, assess the following: i. The appropriateness of the frequency of these self‑audits. ii. The appropriateness of the frequency of audits performed by the campus’s EH&S office in the areas that use chemicals and equipment to ensure compliance. If no such audits are performed, determine why.	Reviewed state law and regulations for criteria regarding self‑audits and laboratory inspections, and assessed if each campus’s policies addressed these requirements. Interviewed key staff and reviewed relevant documentation to determine if campuses performed self‑audits and how frequently they conducted these self‑audits. Reviewed campus policies to determine the frequency of self‑audits and laboratory inspections, and assessed if each campus was in compliance with its policies.
	b. Whether the Chancellor’s Office and campus EH&S offices have sufficient authority to require compliance with all applicable health and safety standards.	Reviewed the executive order issued by the Chancellor’s Office to determine who is assigned the authority to enforce compliance with health and safety requirements on campus. Gathered relevant documentation and obtained perspective from officials from the campuses and Chancellor’s Office on whether EH&S offices have sufficient authority to require compliance on campus. We determined that the four campuses we reviewed have designated campus officials and EH&S department staff with the authority and responsibility for developing and maintaining campus health and safety programs. Nothing came to our attention to suggest that campus EH&S directors do not have sufficient authority to require compliance with all applicable health and safety requirements.
	c. The enforcement actions levied against the Chancellor’s Office and the campuses for health and safety violations during the past five years and the agencies that issued such actions.	Obtained a list of inspections and citations for each campus and the Chancellor’s Office. We also contacted selected enforcement agencies to verify this information and to obtain information about any additional actions they had levied against these entities. Reviewed the supporting documentation to determine which inspections resulted in enforcement actions with monetary penalties and the resulting outcomes for those enforcement actions.

7	Identify the circumstances and the timeline surrounding when administrators at Sacramento became aware of unsafe levels of lead in the campus drinking water and when the campus community was informed of this hazard. Assess the reasons for any delays in informing the campus community.	Interviewed key staff and reviewed relevant documentation to determine the timeline of events surrounding when administrators at Sacramento were informed of potentially unsafe levels of lead in the campus drinking water.

8	Administer a survey to the laboratory instructional support assistants and technicians of each CSU campus to get a general overview of the health and safety climate at the campuses and to obtain staff perspective on laboratory conditions and compliance with existing laws and regulations.	Obtained a list from the Chancellor’s Office of technicians who were exposed to or handled hazardous chemicals. Sent the survey to all technicians on the Chancellor’s Office list. Analyzed survey data and identified patterns. Followed up with selected respondents to obtain additional information to clarify their responses.

9	Review and assess any other issues that are significant to the audit.	We did not identify any other significant issues.

Source: California State Auditor’s analysis of the Audit Committee’s audit request number 2017‑119, planning documents, and analysis of information and documentation identified in the column titled Method.