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California Is Not Adequately Prepared to Protect Its Most Vulnerable Residents From Natural Disasters


Report Number: 2019-103

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Chapter 1

Three Counties Are Not Adequately Prepared to Protect Their Most Vulnerable Residents During Natural Disasters

Butte, Sonoma, and Ventura are not as prepared as they could be to protect their residents during future natural disasters because they have not followed key practices for emergency planning. FEMA and other emergency management authorities have published best practices for effectively planning for natural disasters, including how to assist people with access and functional needs. However, none of the three counties we reviewed fully followed these practices before recent wildfires: the Camp Fire in Butte, the Sonoma Complex Fires in Sonoma, and the Thomas Fire in Ventura. As a result, they lacked up-to-date and complete plans for the key emergency functions of alerting, evacuating, and sheltering their residents. In the absence of such plans, the counties were underprepared to issue effective alerts and warnings, and they struggled to promptly obtain the resources necessary to evacuate and shelter individuals with access and functional needs during recent wildfires. Given the weaknesses we identified in the three counties' plans and the struggles local jurisdictions have had in assisting people with these needs, the State must take a more active role in ensuring that local jurisdictions maintain effective plans for responding to natural disasters.

Selected Sources of Best Practices for Planning for People With Access and Functional Needs


  • FEMA
  • American Red Cross
  • National Council on Disability
  • U.S. Department of Justice


  • Cal OES
  • California Department of Transportation
  • California State Independent Living Council

Source: Publicly available best practices.

The Three Counties Have Not Followed Key Emergency Planning Practices

Despite available guidance and the potentially devastating effects of being underprepared for a disaster, the three counties we reviewed have not followed key practices of emergency planning. California's Emergency Services Act does not require local jurisdictions to develop emergency plans, but FEMA states that leaders in jurisdictions are responsible for taking necessary and appropriate actions to protect people from threats and hazards, which would include natural disasters. FEMA, the American Red Cross (Red Cross), Cal OES, and other entities listed in the text box have published guidance that they advise emergency management agencies to follow so that the agencies develop the best possible emergency plans. Included in this guidance is FEMA's comprehensive guide to emergency planning, which FEMA states is the foundation for emergency planning in the United States and contains the fundamentals of planning and developing emergency plans. Among these practices are having specific plans for critical emergency functions and ensuring that those plans address the needs of the whole community that an agency serves. FEMA and Cal OES have also published guidance that advises emergency planners to prearrange for important resources, such as transportation and shelter supplies. However, the three counties did not fully implement these important practices before the recent wildfires we reviewed, and as Figure 4 shows, the counties still have not done so. As a result, these counties are less prepared for future natural disasters, which may place their residents at greater risk of harm.

Figure 4
The Three Counties Are Not Adequately Prepared for Natural Disasters

An infographic showing that the three counties did not follow key planning practices to prepare for natural disasters.

Source: Emergency planning documentation at Butte, Sonoma, and Ventura, and FEMA guidance.

None of the Counties Have Up-to-Date Plans for Key Emergency Functions

Under the state plan, local governments should have one main plan called an emergency operations plan that assigns responsibility to the appropriate departments within the local government for providing support to people during an emergency. For example, a county may assign responsibility for issuing alert and warning messages to its sheriff's department and assign responsibility for managing emergency shelters to its social services department. As part of the emergency operations plan, counties can develop functional annexes, which are appended to the emergency operations plan and focus on critical operational functions, including how the jurisdiction implements those functions before, during, and after an emergency. Throughout our report, we use the term plan when referring to both the counties' emergency operations plan and their functional annexes. However, at the time of the wildfires we reviewed, the three counties we visited either lacked or had outdated plans for the critical emergency functions of communicating alert and warning messages, evacuating residents, and sheltering evacuees. Butte provided an updated alert and warning plan after we sent a draft copy of our report to Butte for its final comment. Butte provided no evidence that the plan had been approved or finalized. We look forward to reviewing the extent to which the plan incorporates best practices and addresses access and functional needs as part of our 60-day follow-up to this report.

Despite having emergency operations plans, before their recent wildfires, Sonoma and Ventura lacked plans for issuing alerts and warnings and evacuating residents. Ventura also lacked a sheltering plan and Sonoma had only a draft sheltering plan; since the Thomas Fire and Sonoma Complex Fires, neither county has completed any of these plans. As we discuss in more detail throughout this chapter, Sonoma has—in response to the wildfire—taken recent steps toward creating plans or guidance in these key areas of emergency response; however, it has not yet finalized any of its work. Ventura has developed draft plans for alert and warning and sheltering, but for reasons we describe in more detail later, it does not believe it needs a full evacuation plan.

During our review, Ventura stated that a separate plan it developed in May 2016 specifically for addressing access and functional needs (access and functional needs plan) was evidence that it had adequately planned to meet these needs. However, this plan is problematic for several reasons. First, the county has not implemented key portions of the plan, including steps that are advised in FEMA or Cal OES's best practices. For example, FEMA states that local jurisdictions should have plans for alert and warning, evacuation, and sheltering, and that each should include strategies for how the county will assist people with access and functional needs. Although Ventura's access and functional needs plan indicates that Ventura will more fully address how it will meet these needs in separate plans for alert and warning, evacuation, and sheltering—Ventura had not finalized any such plans as of early October 2019. Also, the plan states that Ventura will work to ensure that alert and warning messages are accessible to residents who do not speak English. As we describe later in this chapter, Ventura did not issue alert and warning messages at the beginning of the Thomas Fire in any languages other than English. Finally, having a separate plan for people with access and functional needs is not aligned with Cal OES's guidance. The guidance that Cal OES provides as part of its training on planning to meet access and functional needs states that although plans for specific emergency functions are part of standard emergency planning practices, access and functional needs integration should occur throughout a plan instead of being addressed in a stand‑alone document. Cal OES specifically told Ventura that having a stand‑alone plan was not advisable when it reviewed Ventura's emergency plans in 2016. During that review, Cal OES recommended that Ventura ensure that all of the information in its access and functional needs plan was distributed throughout its emergency operations plan, which it has not done.

Unlike Sonoma and Ventura, Butte had plans for alert and warning, evacuation, and sheltering at the time of the Camp Fire. However, it completed those plans and its emergency operations plan in February 2011, which makes them significantly outdated. FEMA guidance states that maintaining updated plans is critical to the continued utility of those plans and that local jurisdictions should review and update their plans at least every two years. It further states that outdated plans can cause setbacks for local jurisdictions because of old information, ineffective procedures, incorrect role assignments, and outdated laws. Further, state law requires Cal OES to update the state plan every five years, so we would expect that counties would update their plans with at least similar frequency. Weaknesses in Butte's emergency plans support FEMA's observations about potential problems with outdated plans. Some of the response strategies that the plans describe are not reflective of more recent changes to Butte's actual response processes. For example, its alert and warning plan does not discuss Butte's addition of a major federal alert and warning system, the Integrated Public Alert and Warning System, to its repertoire of alert and warning strategies. As a result, the plan does not articulate how the county will use that system during an emergency, which increases the risk that the county will not use it effectively.

In May 2019, Butte convened its public alert and warning working group. According to the sheriff's office liaison (sheriff's liaison) for emergency planning, it created this group to update its 2011 alert and warning plan. Butte provided us with a draft version of this plan in September 2019. The draft includes updated considerations for Butte's alerting methods, including how it plans to use the Integrated Public Alert and Warning System. The sheriff's liaison explained that it updated this plan for several reasons, including recent changes to state law that make its receipt of emergency response funding contingent on having an updated and current alert and warning plan, as well as the county's desire to improve coordination of emergency notifications with neighboring jurisdictions, and to identify the delivery methods of emergency notifications. However, as of early October 2019, this plan remained in draft form, and Butte's plans for evacuation and sheltering were still the versions from February 2011.

According to the county administrative officer at Butte, there are a variety of reasons why it has not updated these key emergency plans. For one, the Great Recession and the recent multiyear drought caused an extended period of limited resources in the county. In addition, county resources have been devoted to responding to and recovering from an increased number of natural disasters, including the 2018 Camp Fire, which we acknowledge is an effort to recover from the most destructive and deadliest wildfire in the history of the State. Nonetheless, it is critically important for Butte to update its plans given the benefits that updated emergency plans could provide to the county, and given that in a hazard threat assessment it released to the public in September 2019, Butte predicted that the county is highly likely to experience a variety of natural disasters in the future.

Advance planning is critical to a local jurisdiction's ability to effectively respond to emergencies because—among other benefits—the plans can clarify responsibilities, identify how to respond in multiple scenarios, and improve the ability to effectively manage response operations in the face of the complexity and uncertainty inherent in natural disasters. According to FEMA, emergencies often evolve rapidly and become too complex for effective improvisation. We recognize—as FEMA states—that using a prescribed planning process cannot guarantee success. However, FEMA has also observed that inadequate plans and insufficient planning are proven contributors to failure. Therefore, to the extent they do not follow key planning practices—such as having up‑to‑date, key emergency plans—these three counties' abilities to effectively respond to natural disasters are likely to be impaired.

The Counties Have Not Adequately Assessed Their Communities to Determine Needs

In addition to missing or outdated plans, before the wildfires the three counties had not adequately tailored their existing emergency plans to the needs of their communities, nor have they done so in the draft plans that they have developed since the fires. FEMA states that the demographics of a population, including its resources and needs, have a profound effect on emergency response functions, such as evacuation and sheltering. It recommends that local jurisdictions conduct demographic assessments of their communities to understand the needs that the people in their communities will have during an emergency. Local jurisdictions can then use this information to help ensure that they can meet those needs. FEMA also warns that failing to base emergency planning on the demographics and requirements of a particular community may lead to false planning assumptions, ineffective courses of action, and inaccurate resource calculations. Despite this guidance, none of the three counties we reviewed has completed an assessment of its population and that population's needs.

According to FEMA guidance, emergency managers should use information compiled from multiple relevant sources—including social service listings and housing programs, among others—when developing an understanding of the number of individuals who have access and functional needs in their community. Using multiple sources enables emergency management agencies to obtain a more precise understanding of the magnitude of the need in their community and of the geographic location or concentration of those needs. Emergency managers can then make more informed decisions about the level of resources they may require during emergencies. General, county-level census data cannot provide this level of specificity.

Ventura's emergency plans do not include any demographic information. The staff emergency manager explained that the county does not conduct demographic assessments before a disaster because it does not have a good source of data, due to individuals moving or passing away. He explained that his department recently developed an interactive map of licensed skilled nursing facilities and group homes, which it can use before and during an incident. Although these data could be helpful during the planning process, they do not capture the full scope of Ventura's vulnerable community. As we discuss in the Introduction, state law includes in its definition of access and functional needs individuals who are homeless, who have transportation disadvantages, or who have limited English proficiency. Therefore, we expected Ventura to have conducted a more complete demographic assessment that includes these individuals to inform its emergency planning.

Butte's and Sonoma's emergency plans contain some demographic information about their populations but lack the more informed estimates called for by best practices. For example, Sonoma's emergency operations plan lists only general census data for the county and Butte's 2015 plan for extreme cold and its 2018 plan for extreme heat indicate that the county has two main populations of individuals who may not understand English. Further, Butte has another emergency plan that its Public Health Department developed in 2015 that contains demographic data from the census and information about the number of skilled nursing and assisted living facilities, among other statistics. Similar to Ventura, this information could be helpful to emergency planning, but it is not representative of the full range of access and functional needs. Also, this information does not appear to have informed Butte's key plans for alert and warning, evacuation, and sheltering as those plans were developed before Butte compiled the demographic information found in its extreme temperature and public health plans.

No County We Reviewed Has Fully Assessed and Prearranged to Obtain the Resources It Would Need in a Disaster

A final, important planning practice that the three counties did not fully address before the wildfires—and still have not fully addressed—is ensuring the availability of critical resources during natural disasters. When a natural disaster occurs, local jurisdictions must obtain a variety of resources to support important emergency response functions, including evacuating and sheltering people. Examples of these resources include accessible transportation and medical supplies for shelters. FEMA guidance states that during the planning process, local jurisdictions should conduct assessments of the resources that they will need during disasters and identify how they will obtain those resources; for example, by developing memoranda of understanding. The state plan says that public-private partnership agreements can provide for quick access to emergency supplies and essential services. However, as we describe in this chapter, none of the counties have prearranged transportation agreements for providing evacuation assistance. Although Butte has prearranged for many emergency shelter supplies, neither Sonoma nor Ventura have made arrangements to obtain key resources for sheltering, such as accessible cots.

The Three Counties Varied in Their Views on Implementing These Planning Practices

The counties differed in their perspectives regarding adherence to these key planning practices. According to Butte's county administrative officer, Butte cannot take on additional planning responsibilities without financial and technical assistance from the State. Ventura was agreeable to implementing some, but not all, of the best practices. For example, the staff emergency manager agreed that Ventura should create a more standardized approach in developing its emergency plans, including engaging with representatives of access and functional needs when developing the plans. However, he did not agree with the practice of developing an all-hazards evacuation plan. Rather, he believed that Ventura's current approach to managing evacuations has been effective.

Following the Sonoma Complex Fires, Sonoma developed and approved a plan it calls its recovery and resiliency framework. This framework describes steps that Sonoma plans to take to recover from the wildfires and improve its preparedness for future natural disasters, as well as timelines for accomplishing these steps. Included among these steps are actions that overlap with some of the best practices that we reviewed and describe throughout this chapter. For example, the framework states that Sonoma will develop a comprehensive alert and warning program, it will identify essential services and resources necessary during a disaster and, to the extent possible, it will have contracts or memorandums of understandings in place. The plan also makes repeated references to the vulnerability of persons with access and functional needs during natural disasters and specifically states that to achieve equity, Sonoma will identify and meet the needs of these populations before, during, and after natural disasters.

Despite this commitment to improving its preparedness through best practices, Sonoma's director of emergency management expressed concern at how costly some of the practices we discuss in this report are to implement, how impractical he believes it would be to implement them, and how not all best practices are relevant to all organizations. For example, he believes that no county emergency management agency in California currently conducts the type of demographic assessments that FEMA recommends as part of the emergency planning process because of the costs associated with regularly updating such an assessment. Although he could not provide a formal estimate of the costs of implementing best practices for addressing access and functional needs, he provided a gross estimate that doing so would require at least 10 percent more spending on emergency planning and preparedness efforts. Using the fiscal year 2019–20 budget for Sonoma's department of emergency management, that equates to roughly $360,000. The director of emergency management did not specify whether his cost estimate accounted for the actions Sonoma has already committed to completing in its recovery and resiliency framework.

It is impossible to determine whether any additional planning efforts by the counties would have changed the outcomes of the Camp Fire, Sonoma Complex Fires, and Thomas Fire, which were devastating and unprecedented. However, as we describe in the following sections, these counties' planning deficiencies likely hindered their response to recent wildfires, in particular related to protecting and assisting people with access and functional needs. In the remainder of this chapter, we describe our review of each county's plans in key areas that relate to protecting and assisting people with access and functional needs as well as the counties' processes during planning for ensuring that they can meet those needs. Figure 5 summarizes those areas.

Figure 5
We Reviewed Key Areas of Emergency Management at Each of the Three Counties

A graphical symbol for each of the four key areas of emergency management that we reviewed, including emergency plan development, alert and warning, evacuation, and sheltering.

Source: Auditor analysis, state law, and FEMA guidance.

Despite Available Best Practices, None of the Three Counties Adequately Involved Representatives of People With Access and Functional Needs in Its Planning Process

Actions Counties Should Take to Involve Community Organizations in Emergency Planning

  • Meet with them frequently to discuss emergency preparedness.
  • Identify the resources at their disposal to aid their clients during emergencies.
  • Aid them in developing emergency plans for themselves.
  • Involve them in training and exercises.
  • Include representatives from the organizations on committees that approve emergency plans.

Source: Cal OES guidance.

Best practices from FEMA and Cal OES suggest that emergency management agencies should involve individuals with a variety of access and functional needs in all aspects of the planning process because those individuals understand what they will need during disasters. For similar reasons, the best practices also recommend involving local community organizations that serve these individuals. For example, organizations that provide services to people who are deaf or hard of hearing can provide information on how counties should communicate critical information, such as evacuation alerts, to such individuals during emergencies. Further, Cal OES's guidance notes that community organizations already have established networks in the communities they serve. The text box identifies examples of actions from Cal OES guidance that counties should take to involve such community organizations in their emergency planning. As Figure 6 shows, the three counties we reviewed all have significant populations of people with access and functional needs; however, the counties did not adequately involve representatives of these people in their emergency planning efforts.

Butte and Sonoma asserted that they had, to some degree, involved these representatives in the development of their emergency plans. Specifically, Butte and Sonoma generally stated that they had met with one to two organizations representing people with certain access and functional needs during the development of their emergency plans. In addition, Sonoma stated that it brought its draft emergency plan to a meeting with one of the organizations for its members to review, and Butte asserted that it included the organizations it met with in its planning discussions. However, neither county was able to provide documentation demonstrating the level of involvement that these organizations had in the planning process. Staff at both Butte and Sonoma stated that they did not retain that documentation because their document retention policies required them to destroy it. Sonoma's director of emergency management further stated that retaining that documentation is not an industry standard.

Figure 6
The Counties Have Significant Populations of People With Access and Functional Needs

A bar chart showing that there are significant populations of people who are older, have limited English proficiency, or have disabilities in each of the three counties we reviewed.

Source: U.S. Census data for Butte, Sonoma, and Ventura.

Note: Some people may be counted more than once because they have multiple access and functional needs. For example, a person with limited English proficiency may also have a disability.

When we asked Ventura's staff emergency manager whether Ventura had included representatives of people with access and functional needs in its emergency planning process, he indicated there were two ways in which he believed it had done so. First, he explained that Ventura's emergency planning council, which is responsible for reviewing and adopting emergency plans, includes a representative for nongovernmental organizations, and he claimed that this individual coordinates input from a few organizations that represent specific access and functional needs populations. However, this planning council is not involved in developing the emergency plan, and the organizations that Ventura claimed are represented by this individual are not inclusive of all types of access and functional needs. The staff emergency manager also stated that the county's plan for access and functional needs was developed in partnership with representatives of people with those needs. This plan states that its purpose is to provide an overview of Ventura's policy with respect to emergency planning and emergency services for citizens with access and functional needs. It further states that Ventura would establish and coordinate a planning group with a diversity of access and functional needs represented and that this group would ensure that Ventura's emergency plans were inclusive. However, according to the staff emergency manager, this planning group was used solely for developing this access and functional needs plan, and the group no longer exists. Further, he is neither aware of nor does he have documentation as to who was part of this planning group because he was not responsible for organizing the group. As we describe earlier, we determined that Ventura's separate plan for addressing access and functional needs was counter to best practices, which recommend that emergency planners integrate plans for meeting access and functional needs into the overall plans rather than creating a separate plan. We also determined that Ventura has not followed through with key tasks that the plan said it would perform in advance of a disaster.

The practices that the counties described to us fall short of the best practices we identified for involving individuals with access and functional needs in planning. FEMA states that the most realistic and complete emergency plans are prepared by a diverse planning team that includes, among others, representatives of people with a variety of access and functional needs. As our Introduction describes, access and functional needs is a term that encompasses many needs or challenges that individuals may have. Emergency management agencies must plan to employ multiple strategies to meet these various needs and challenges during an emergency. By consulting only a few of these organizations, the counties have not obtained participation and viewpoints from the full range of people with access and functional needs in their communities. For example, none of the counties claimed to have engaged communities with limited English proficiency when developing their existing emergency plans, which would limit their ability to incorporate these communities' perspectives in their planning.

Further, when we spoke to several community organizations in each of the three counties, the majority reported that their county's emergency management agency had never consulted or involved them. Some of these organizations also reported that during the recent wildfires, they provided direct assistance to people with access and functional needs. However, the counties had apparently not taken advantage of these vital sources for critical information, thereby missing an opportunity to learn what individuals in these communities need during natural disasters and how the counties could prepare to meet those needs.

An additional benefit of involving organizations that serve people with access and functional needs in emergency planning is that it may increase individuals' preparedness. However, because the counties did not adequately involve these representatives, they missed an opportunity to realize this benefit. According to FEMA guidance, including community leaders in planning reinforces the expectation that community members have a shared responsibility during natural disasters and strengthens the public's motivation to conduct planning for themselves and their families. As Figure 7 indicates, people with access and functional needs can take numerous actions to prepare themselves for natural disasters. These actions can make a significant difference in ensuring their safety when a natural disaster occurs. By doing more to engage communities of people with access and functional needs in their planning processes, counties can encourage everyone's emergency preparedness.

Butte's emergency manager believed that until recent significantly sized events in 2017 and 2018, the planning process that Butte used had proven to be adequate. However, she stated that she will ensure that Butte follows best practices and communicates with representatives of people with access and functional needs when developing its emergency plans. Similarly, Ventura's staff emergency manager agreed that Ventura should engage representatives of these communities in future planning efforts. However, he also questioned whether many organizations exist in Ventura County that represent individuals with disabilities because he was not personally aware of them. As we discuss earlier, counties should involve representatives of people with a variety of access and functional needs, not just people with disabilities, in the planning process.

Sonoma's director of emergency management disagreed with our assessment of how well the county involved representatives of individuals with access and functional needs in its emergency planning process. However, he was unable to provide documentation to refute our conclusions. For example, he stated that his department sought feedback from the county's access and functional needs committee when developing its emergency plans, including its draft alert and warning plan. However, the chair of this committee—which includes representatives from various access and functional needs communities—stated that although he was aware that Sonoma was developing an alert and warning plan, the committee has not been involved in that process. Further, the chair noted that there is no formal process at Sonoma for ensuring that the committee he chairs is incorporated in the planning process. FEMA states that representatives of access and functional needs communities should be incorporated into all aspects of the planning process. In the sections that follow, we describe the counties' responses to natural disasters and how more adequate planning could have supported their response efforts.

Figure 7
People With Access and Functional Needs Can Take Steps to Prepare for Natural Disasters

An infographic showing some specific steps that people with access and functional needs can take to protect and prepare themselves for a natural disaster.

Source: Best practices from FEMA, Cal OES, and the National Council on Disability.

None of the Three Counties Prepared Adequately to Warn Residents of Impending Danger From the Wildfires

When natural disasters occur and threaten people's safety, timely alert and warning messages can mean the difference between life and death. These emergency communications are directed at the public to attract their attention and, in some cases—such as evacuation warnings—persuade them to take action to protect themselves. Alert and warning messages are most effective when emergency management agencies issue them quickly and ensure that they are understandable. Any delay in people's receipt or understanding of alert and warning messages directing them to evacuate or otherwise protect themselves can threaten their safety or even their lives. Alerting agencies can use several methods to send these important messages, as the text box shows.

Methods That Governments Can Use
to Alert and Warn Residents

  • Voice messages
  • Text messages
  • Emails
  • Social media
  • Websites
  • Teletypewriters (TTY)
  • Radio
  • Television
  • Door-to-door notifications
  • Loudspeakers through neighborhoods
  • Sirens

Source: FEMA, U.S. Department of Homeland Security, and Cal OES guidance.

Best practices for alerting and warning the public about natural disasters identify key issues that counties should consider when establishing their approaches to emergency communications. First, FEMA and Cal OES suggest that because no single method will reach all people, counties should plan to use several methods to maximize the number of people who receive an alert or warning. In addition to addressing the diverse ways people receive information, this approach can also help messages reach intended targets when a natural disaster has destroyed key infrastructure used to transmit such messages. Also, the U.S. Department of Homeland Security encourages emergency management agencies and other alerting authorities to plan for the accessibility of their messages so as to better reach populations with access and functional needs. For example, agencies can alert people who are deaf by ensuring that messages are written because people who are deaf would be unable to hear an audio phone call or listen to a radio broadcast for emergency information.

However, despite the critical importance of alert and warning messages, the counties we reviewed did not fully adhere to best practices for planning to issue these messages. As discussed previously, none of the counties had updated alert and warning plans. FEMA guidance states that an alert and warning plan should identify and describe the actions that locals will take to initiate and disseminate the initial notification that a disaster or threat is imminent or has occurred. This guidance further states that this plan should identify and describe the actions that will be taken to alert individuals with sensory or cognitive disabilities and others with access and functional needs in the workplace, in public venues, and in their homes. As noted earlier, Butte had an alert and warning plan, but it was outdated, as it made no mention of a significant federal alert system that it had access to. Ventura had standard operating procedures that describe the use of one specific system that it uses for sending alert and warning messages. Although the staff emergency manager asserted that this set of procedures was Ventura's alert and warning plan, the procedures did not address all of the key components of Ventura's warning system. Further, procedures for operating a specific alerting system are not a sufficient replacement for a comprehensive alert and warning plan.

Benefits of Using a WEA Instead of Opt‑In
Emergency Notification Systems


  • Can reach all cell phones in an area.
  • Generates unique alert tones and vibration pattern.
  • Not affected by cellular network congestion.

Opt-In Systems and Landline Contact Information

  • Reaches only landlines and cell phones that owners have preregistered to receive alerts.
  • Looks and sounds like a regular text message or phone call.
  • Disrupted by cellular network congestion.

Source: U.S. Department of Homeland Security, FEMA, and Cal OES guidance regarding alert and warning systems.

All three counties asserted that they used multiple methods for alerting and warning people during the wildfires we reviewed, including many of the methods listed in the earlier text box. As we previously describe, the size and scope of those wildfires were devastating and unprecedented. We recognize that even if the counties had implemented all best practices related to issuing alert and warning messages, it is unlikely that they would have alerted every single person within their evacuation zones because of infrastructure challenges and the limitations of any given alerting method. However, as noted above, employing the best practices can help counties to maximize the number of people who receive critical alert and warning messages. By not implementing these best practices in their planning, the counties impaired their abilities to effectively warn residents of the impending dangers from the wildfires we reviewed, as Figure 8 shows.

Butte and Sonoma Did Not Send Messages That Could Reach All Residents With Cell Phones

In response to the recent wildfires, neither Butte nor Sonoma alerted their residents using a system designed to send warning messages to all cell phones in the evacuation area. FEMA built a system that allows emergency management agencies and other alerting authorities to issue alert and warning messages called Wireless Emergency Alerts (WEA messages). As the text box describes, using the federal system to send WEA messages provides distinct advantages over the use of opt-in emergency alert systems and landline contact information. These advantages give WEA messages the capacity to alert a significantly greater number of people in an evacuation zone, including people with access and functional needs. During the Thomas Fire, Ventura issued WEA messages to notify people about the threat and direct them to more disaster information.

However, neither Butte nor Sonoma issued WEA messages during the Camp and Sonoma Complex Fires, respectively. Instead, these two counties issued emergency messages through their local emergency alert and warning systems. According to the counties, their systems use contact information, such as cell phone numbers, that residents provide, as well as landline contact information that the counties purchase from service providers. However, using only these opt-in systems is inherently problematic given the public's declining use of landlines and the small percentage of people who sign up for cell phone alerts. For example, in the aftermath of the Sonoma Complex Fires, the number of phone numbers registered to receive alerts and warnings through Sonoma's opt-in system represented fewer than 60 percent of the residents of the county. Consequently, even if every resident who had registered received the evacuation warnings that Sonoma sent, a significant percentage of the county's residents still did not receive these critical notifications. Moreover, Sonoma's records show that about 60 percent of the phone calls it made failed to connect, and for Butte, the failure rate was about 50 percent, meaning that many people in the evacuation zones did not receive these critical messages. Although the two counties also used some other methods to alert people during the wildfires, such as email and—in the case of Butte—social media, none of these methods have the ability to reach as many people as quickly as WEA messages.

Figure 8
None of the Counties Adequately Warned Residents of Impending Danger From Wildfire

An infographic showing that during recent wildfires, none of the counties we reviewed adequately warned residents of the impending danger.

Source: Alert and warning records at Butte, Sonoma, and Ventura.

The fact that neither Butte nor Sonoma issued alerts and warnings through WEA messages during recent emergencies appears related to deficiencies in their preplanning for a natural disaster. Butte asserted that it attempted to issue a WEA message in the immediate hours after the Camp Fire began but that the messages failed to send through the software program it uses. FEMA guidance on WEA indicates that counties should test their software to ensure that it is functional before using it in a natural disaster. However, staff at Butte acknowledged that they had never tested Butte's software before the Camp Fire. Although testing does not guarantee that problems will not happen during a natural disaster, it is a reasonable step that Butte should have taken. Although Butte still has not finalized plans for issuing WEA messages, it has issued WEA messages to warn residents about potential flooding and to issue evacuation notices since the Camp Fire.

According to Sonoma's director of emergency management, who was not in his position during the Sonoma Complex Fires, the county did not issue a WEA message during the fires because the county—under the leadership of the previous emergency manager—planned in advance not to do so. According to Cal OES's post-event review, emergency management in Sonoma believed that the WEA system had limitations, including that it would send messages to those who were not in the intended evacuation zone. Cal OES concluded that staff largely based their decision not to issue a WEA message on their experience, previous policy discussions, and perceived knowledge of the situation; however, they were also influenced both by their limited understanding of the WEA system, referencing Sonoma staff's belief that issuing a WEA message would cause traffic congestion, and by outdated information regarding its capabilities. According to Sonoma's current director of emergency management, at the time of the Sonoma Complex Fires, there was national discussion regarding local governments' concern about using the WEA system for various reasons. He provided a July 2017 letter that Harris County, Texas, submitted to the Federal Communications Commission wherein it shared concerns about the WEA system, including a concern regarding the system's inability to more accurately target areas for alerts. In September 2018, Sonoma conducted a test of the WEA system. In a report summarizing the results of the test, Sonoma noted that the test findings indicated that significant challenges remained regarding the effective use of the WEA system, including incomplete and inconsistent alerting across telecommunication providers, significant bleed-over when targeting specific geographic locations, and the performance of the technology across various wireless devices. The report noted that local emergency managers would have to take these shortcomings into account when developing alert and warning efforts. However, since the fires, Sonoma has created a draft alert and warning plan that includes plans to issue WEA messages during future disasters. Additionally, Sonoma has since issued WEA messages during more recent emergencies, which suggests that Sonoma recognizes additional benefits to issuing a WEA message despite the limitations it believes the system has.

The Content of Butte's and Sonoma's Alert and Warning Messages Did Not Align With Best Practices

In addition to not sending warnings using the WEA system, Butte and Sonoma did not ensure that the content of their alert and warning messages aligned with best practices. FEMA advises that plans for alert and warning should include pre‑scripted messages for specific hazards. According to FEMA, effective warning messages should contain certain key elements, including the source of the warning, the specific hazard and its location, and the protective action that the public should take. However, Butte and Sonoma did not always include all of these elements in the messages that they sent through their opt-in and landline systems. For example, as the example messages in Figure 9 demonstrate, Butte never identified the entity sending its evacuation warnings during the Camp Fire. FEMA advises that warnings should come from sources with credibility, and the National Council on Disability states that the response individuals have to an emergency alert depends in part on the level of trust they have in the source. Therefore, Butte's content in its warning messages made it less likely that recipients would perceive a warning as credible, and they would be less likely to act on it.

According to the sheriff's liaison, the messages did not comply with best practices because Butte's emergency staff was rushed. However, he acknowledged that developing message templates in advance would be beneficial in ensuring that alert and warning messages incorporate key elements, and Butte finalized those templates in October 2019. The templates include the source of the warning messages.

The alert and warning messages that Sonoma issued during the Sonoma Complex Fires contained the key elements identified in best practices more often than those that Butte issued. Unlike Butte's evacuation warnings, Sonoma almost always included the source of the warnings. However, its messages did not consistently identify the specific hazard. Instead, the county sometimes told recipients to evacuate without telling them that a fire was approaching. By not identifying the specific hazard, Sonoma risked that recipients of those warnings would not understand the severity of the impending danger. When we asked Sonoma's director of emergency management why its messages did not consistently identify the hazard residents faced, he said he could not speculate on the reason because he was not the director of emergency management at the time of those fires. Sonoma has since developed pre-scripted messages for use during natural disasters, and they guide the staff sending the alert to include the nature of the threat.

Figure 9
The Messages That Butte and Sonoma Issued During the Recent Fires Did Not Align With Best Practices for Ensuring That They Were Effective

A picture of three cell phones showing examples of emergency messages that each county issued during recent wildfires and whether these messages aligned with best practices.

Source: Analysis of FEMA best practices and emergency alert and warning records from Butte, Sonoma, and Ventura.

Among the three counties, the alert and warning messages that Ventura sent most consistently aligned with best practices. Those messages almost always contained the source of the message, a description of the hazard, and the protective action that recipients should take. Ventura's preparation for natural disasters seems to explain the significantly better messages it sent during its wildfire. Unlike Butte and Sonoma, Ventura had followed the best practice of developing message templates in advance, which expedited its ability to issue alert and warning messages and to ensure that such messages contained each of the key elements.

None of the Three Counties Sent Crucial Messages in Languages Other Than English

Finally, despite their having significant populations of residents with limited English proficiency, all three counties issued messages directing people to evacuate in English only. As a result, some people likely did not receive potentially lifesaving emergency information in a language that they could understand. FEMA guidance states that communities with high percentages of non‑English-speaking residents should consider issuing warnings in multiple languages. FEMA further recommends using pretranslated templates—similar to the pre-scripted English templates we mention above—to minimize the amount of information that would require translation for actual alerts. A local community organization in Ventura told us that during the Thomas Fire, parents with limited English proficiency had to rely on their children for help translating emergency messages. According to this community organization, relying on children to translate made it difficult for individuals to assess the danger of their situations. After that community organization complained to the county about the lack of translated information, Ventura began translating information into Spanish. However, it did not issue its first messages in Spanish until 10 days into the wildfire—too late for those who needed to evacuate before that time. Ventura stated that the need for it to issue alerts in Spanish is evident in hindsight and that it had never previously received feedback that it needed to issue emergency alerts in other languages. During subsequent natural disasters, Ventura has issued alert and warning messages in Spanish and maintains a set of pre‑scripted Spanish messages.

Butte and Sonoma offered their own explanations for why they issued evacuation messages only in English. In Butte, the sheriff's liaison stated that staff members did not issue messages in languages other than English because they were rushed. He acknowledged that having prepared scripts for the translated messages would be beneficial. In October 2019, Butte completed templates in both Spanish and Hmong, the two primary non-English languages in Butte County. Sonoma asserted that it did not issue messages in languages other than English because when the Sonoma Complex Fires began, the emergency coordinator responsible for issuing messages was out of town and issued evacuation warnings remotely without access to translation services or translated messages. However, we question this explanation because Sonoma never issued any alert and warning messages in any language other than English during the duration of the fire. When counties do not provide translated evacuation warnings, residents who do not speak English may unknowingly remain in unsafe locations or may have to find others to translate the messages for them, delaying their ability to safely evacuate. Since the Sonoma Complex Fires, Sonoma has issued emergency alerts in Spanish.

The Unprecedented Wildfires Challenged the Three Counties' Abilities to Provide Evacuation Assistance

As we discuss in the Introduction, the recent wildfires in the three counties we reviewed were devastating and unprecedented. During these fires, there were significant acts of heroism by firefighters, law enforcement officers, and civilians while fighting the fires and while evacuating residents. The actions of these first responders and others saved lives and prevented each of the fires from being even more deadly and destructive than they ultimately were.

However, first responders in each county also reported to us challenges in obtaining sufficient resources to quickly provide evacuation assistance to some of the people who may have needed such help. During natural disasters, people with disabilities may not be able to evacuate without accessible transportation, such as wheelchair-accessible buses, and first responders in each of the counties told us that accessible transportation options were limited during the responses to those fires. The first responder in Ventura, who is a sergeant in the sheriff's department's tactical response team, stated that such resources were not needed during the Thomas Fire, but had they been needed, it would have been challenging to provide them given the limited resources available at the time. Additionally, we spoke to community organizations that represent or provide services to people with access and functional needs in each county. Some of these organizations in Butte and Sonoma stated that the resources to support evacuating the clients they serve were overwhelmed by the disasters.

We recognize that no amount of planning or preparation will guarantee that a county is fully prepared for a natural disaster. This is particularly true in cases like those we reviewed, in which the natural disasters were historic in size and scope. Moreover, determining whether any additional lives would have been saved during these events if the counties had planned differently or more fully implemented the best practices that we discuss in this report is impossible, and we reach no conclusions to that effect. Further, FEMA acknowledges that using a prescribed planning process cannot guarantee success, although it also notes that inadequate plans and insufficient planning are proven contributors to failure. Before the recent fires, the three counties did not implement critical best practices to ensure that they were as prepared as possible for evacuating individuals during natural disasters, as Figure 10 shows.

Figure 10
None of the Three Counties Adequately Planned to Assist Evacuees During Natural Disasters

An infographic showing that the counties had not adequately planned to assist evacuees during natural disasters by following best practices.

Source: Evacuation plans and planning documentation at Butte, Sonoma, and Ventura.

The Three Counties Either Lacked or Had Outdated All-Hazard Evacuation Plans

Two of the three counties—Sonoma and Ventura—had not adopted evacuation plans applicable to all types of potential disasters in their areas. FEMA best practices suggest that counties should develop all-hazard evacuation plans that broadly apply to a wide range of emergencies, including different types of natural disasters. FEMA guidance describes several elements that should be included in these plans, such as traffic control measures, the local jurisdiction's provisions for evacuating individuals with access and functional needs, and processes for tracking children, especially unaccompanied minors. As Figure 10 shows, none of these three counties had updated all-hazard evacuation plans. Butte did have an all-hazard evacuation plan, but it was more than seven years old at the time of the Camp Fire. Further, although Butte's plan states that it is designed to be used for all potential hazards, it is not aligned with all-hazards evacuation planning best practices and does not address how Butte plans to support residents with access and functional needs during an evacuation. Sonoma and Ventura each have hazard-specific plans for tsunamis and flooding, but—in addition to not considering all hazards—these plans also lack strategies for how the counties plan to address residents' access and functional needs during evacuations.

Sonoma's director of emergency management stated that the county is in the process of developing additional evacuation plans; however, he could not explain why Sonoma did not have an all‑hazard evacuation plan before the Sonoma Complex Fires because he was not in his position at that time. Nonetheless, he indicated that the county's current strategy for developing such a plan includes adopting specific plans for communities with evacuation challenges. Since the Sonoma Complex Fires, Sonoma has developed a framework for recovery and resiliency that states that it plans to work with community and neighborhood liaisons to identify hazards, risks, and mitigation strategies, including evacuation routes.

Conversely, Ventura's staff emergency manager stated that Ventura does not intend to develop an all-hazard evacuation plan because he believes its current dynamic, real-time approach has not hindered its ability to respond to emergencies. However, if an emergency management agency assumes it will be able to respond effectively to all future natural disasters because its previous response efforts were successful, it may not be prepared for events that are larger and more complicated than those it has faced in the past. As an example, Sonoma's after-action report for the Sonoma Complex Fires noted that the county had experienced a large number of natural disasters before the 2017 fires and that much of Sonoma's preparedness efforts had been designed to be prepared for disasters of similar size. Sonoma's report concluded that these past experiences were insufficient in preparing the county for the 2017 fires. Therefore, Ventura should not evaluate its need for changes to its emergency preparedness based solely on the disasters it has already experienced. Rather, it should strive to be as prepared as possible to provide evacuation assistance to those with access and functional needs during a natural disaster.

The Three Counties Had Not Made Arrangements to Improve Their Ability to Provide Evacuation Assistance to All Who Needed It

FEMA and Cal OES guidance both recommend that emergency management agencies prearrange resources for evacuation assistance to help ensure that those resources are available during natural disasters. Cal OES specifically developed a sample agreement for transportation resources. The sample agreement guides local jurisdictions to define important considerations in these agreements, such as who has the authority to activate the agreement, the time frame within which the transportation authority should be able to respond to requests for assistance, and estimates of how many resources the transportation provider can provide. However, none of the three counties had made such prearrangements before the recent fires. Ventura asserted that it had master agreements that would allow it to leverage accessible transportation resources for evacuation assistance for residents during an emergency. However, these agreements often specified that the transportation vendors would furnish bus tokens or passes, and none of them referenced how Ventura might use these agreements during an emergency. Further, even as of the time of this audit, none of the three counties had bolstered their available evacuation resources by establishing prior agreements with transportation entities to provide evacuation assistance during natural disasters. Rather, each has planned that its emergency operations center will locate and request transportation assistance during the emergency, which requires additional time that preplanning these arrangements could reduce.

Best practices recommend that counties include public transit and transportation agencies in their emergency planning efforts. To this end, the California Department of Transportation has published guidance for public transit operators on how to assist local jurisdictions in evacuations during natural disasters, and it recommends that representatives of local transit operators be a part of emergency planning teams and memorialize in writing their agreements with emergency management agencies. First responders in Sonoma and Ventura agreed that having arrangements in place before a disaster strikes would benefit their evacuation efforts. However, the county administrative officer for Butte disputed the necessity of such agreements, stating that Butte's regional transit authority provides resources upon request by emergency management or the sheriff's office, and claiming that because of limited resources locally, Butte depends on the State's mutual aid system for large events. Despite these assertions, because Butte has not conducted demographic assessments to determine how many people within the county may need evacuation assistance during a natural disaster, it cannot know whether the resources that the regional transit authority has available will be sufficient for all who need assistance. Further, as we indicate earlier, agreements with transit authorities provide other benefits, such as clearly defining who is allowed to activate the agreement. Waiting until a disaster occurs to arrange for that assistance means local jurisdictions risk having difficulty locating and coordinating sufficient evacuation resources, such as local transit operators and accessible vehicles. These difficulties may unnecessarily delay potentially life‑saving assistance.

The Three Counties Had Not Fully Assessed How Many People May Need Evacuation Assistance

Finally, the three counties did not leverage all available information to identify the people in their communities who might need evacuation assistance and to address those people's needs in their evacuation plans. As we describe earlier, none of the three counties had followed the emergency planning best practice of conducting demographic assessments of its population. In particular, the counties did not use existing data—available through a variety of public programs—to identify the number and concentrations of people with access and functional needs in their communities or in developing their emergency plans.

For example, each of the counties has an agency that provides in‑home supportive services (IHSS) to aged and disabled people. These agencies maintain lists of people who receive IHSS and who will require assistance during an evacuation. The managers of the three IHSS agencies stated that when the counties declare local emergencies, county staff members attempt to call people on the lists to determine whether they need evacuation assistance and then the staff members notify law enforcement if so. Although these calls can help a county facilitate evacuation assistance to some people, they are limited to those receiving IHSS. Butte also enables residents with access and functional needs who do not receive IHSS to provide their contact information to the county and indicate that they will need evacuation assistance. Butte stated that it also makes calls to these individuals during a natural disaster. According to a program manager in Butte's department of employment and social services, Butte informs the public about the option to provide their contact information through its website, during social workers' home visits, and during public outreach events.

However, despite the value of IHSS information for planning purposes, neither Butte nor Ventura used this information when creating their emergency plans. Instead, each asserted that it makes use of data on people with certain access and functional needs once a disaster occurs, which deprives emergency responders of the benefits of having this information available beforehand. Further, emergency managers at Butte and Ventura asserted that emergency planners cannot obtain IHSS lists before a disaster occurs because the lists contain health-related information that is protected by federal and state law. Ventura's chief deputy director of human services explained that the county asks its IHSS clients to sign waivers to allow her agency to notify law enforcement about their location before the county issues a local emergency order. However, she said that based on the county's understanding of state law, she is not permitted to offer information about the location of IHSS clients to first responders until a threat has become impending and urgent.

We are concerned that by not sharing this information before disasters occur, the two counties are missing an opportunity to better prepare to provide evacuation assistance. We believe that county agencies could provide general information to emergency planners about IHSS clients—such as the neighborhoods that have high concentrations of people who need assistance—without violating state law's restrictions on information sharing. By not making use of existing county data when planning for emergencies, the counties are missing an opportunity to expedite evacuation assistance when natural disasters occur.

Sonoma also did not use available data to develop all of its emergency plans in the past, but unlike Butte and Ventura, Sonoma has recently leveraged available data to inform a new plan. Its human services department has formally committed to providing its department of emergency management with a copy of its updated IHSS client list each week, which allows responders to understand the level of response an IHSS client may need in an emergency situation. Sonoma has used these data in part to develop a new plan that focuses on responding to decisions by utilities to interrupt service in an attempt to prevent wildfires. This plan relies in part on IHSS data to assess the general volume of individuals in the community who may be dependent on electricity to address medical conditions.

Such a practice shows the value of this information for emergency preparedness and planning and how not leveraging these data in other planning efforts can hinder the effectiveness of those plans. The chair of the Sonoma access and functional needs committee—who also manages the IHSS program—agreed that detailed assessments of its access and functional needs residents would help the county to be better prepared to meet a variety of needs. However, he did not know why Sonoma had not used such assessments in the development of other emergency plans.

The Three Counties Had Challenges Obtaining Certain Resources to Support People With Access and Functional Needs in Emergency Shelters

Key Resources for Ensuring That Shelters Are Accessible to People With Disabilities

  • Accessible parking
  • Pathways wide enough for wheelchairs
  • Accessible beds or cots
  • Accessible toilets, showers, and hand-washing stations
  • Braille and navigable pathways for people who are blind
  • Teletypewriters (TTY) for people who are deaf

Source: U.S. Department of Justice.

When counties conduct evacuations, they may also open emergency shelters where evacuees can stay before, during, and after a disaster. These shelters provide indoor space, food, water, and sanitation to maintain the evacuees' basic well-being until they can return home. Under the Americans with Disabilities Act, emergency programs provided by public entities, including emergency shelter programs, must be accessible to people with disabilities. As the examples in the text box show, this includes ensuring that shelters can meet the basic human needs of people with disabilities, including the ability to maneuver inside the shelter, sleep, use the restroom, and shower. Best practices suggest that shelter staff should also be able to provide first aid, medicine, and medical equipment, such as wheelchairs, canes, and oxygen tanks. People who evacuate may leave behind this equipment, but without it, they may not be able to function independently or even survive.

It would be unreasonable to expect that counties could meet all of the needs of every evacuee immediately upon arrival at a shelter during a natural disaster, especially during unprecedented disasters like the three recent wildfires that we reviewed, when thousands of people sought shelter. However, adherence to best practices regarding establishing and operating emergency shelters enables counties to be better positioned to quickly meet the needs of evacuees, including those with access and functional needs. Despite that benefit, the counties we reviewed did not follow key best practices—including having updated sheltering plans with strategies for meeting access and functional needs—which may have impaired their ability to promptly obtain certain resources to support people with access and functional needs in shelters during the wildfires we reviewed.

Each county retained only limited documentation of the conditions in the shelters they established during the recent natural disasters we reviewed. Therefore, our analysis was limited to what we could determine from reviewing logs of resource requests and available payment or billing records, examining the counties' after-action reports containing county staff's review of the effectiveness of the counties' emergency responses, and speaking with staff who supported the shelters during the disaster responses. Managers who oversaw the shelters in Butte and Sonoma stated that the size and scope of the wildfires created challenges in promptly obtaining some supplies, including accessible cots, toilets, and showers. The records and statements we reviewed indicate that each county had difficulty obtaining at least one key resource necessary to make shelters fully accessible to people with disabilities. Specifically, Butte had difficulty obtaining accessible showers for its shelters. Butte's director of employment and social services said that during the Camp Fire, she requested assistance from Cal OES in obtaining showers but believes they took several days to arrive. She stated that to compensate for the lack of showers, Butte offered to transport people with disabilities to other shelter locations so they could shower. Similarly, documentation from Sonoma indicates that it had challenges obtaining sufficient accessible showers, and documentation from Ventura shows that it struggled to obtain a sufficient number of accessible cots.

Although the counties ultimately received some of these resources, delays in obtaining them can create significant discomfort for people with access and functional needs. For example, without an accessible cot, people with disabilities may not be able to lie down independently or at all. Similarly, the lack of accessible showers can result in people with disabilities being unable to shower without assistance. Staff at each of the counties acknowledged they had problems promptly obtaining certain supplies, and they stated that they did what they could to make people in the shelters comfortable while they waited for delivery of those supplies.

The Counties Did Not Assess What Their Communities Would Need in Shelters

As we discuss earlier, best practices state that counties should conduct demographic assessments to understand what needs the people in their communities may have during an emergency. As part of those assessments, best practices indicate that in shelter planning counties should be prepared to meet access and functional needs. According to FEMA, as a general rule, about 10 to 15 percent of a population will require housing in a public shelter after an evacuation. However, it also states that the demographics of a population can have a profound effect on shelter operations. FEMA recommends that in planning for shelter capacity, counties know the demographic profiles of their communities and understand the type of assistance that their various populations may require during a disaster.

However, none of the three counties performed such demographic assessments. Emergency managers in Butte and Sonoma instead used general estimates for the percentage of evacuees who would require shelter and the percentage who would have access and functional needs. For example, Sonoma's plan stated that, historically, in most events fewer than 10 percent of evacuees seek shelter and that between 20 and 25 percent of shelter occupants may have access and functional needs. Ventura's chief deputy director of the human services agency (chief deputy director) stated that before the Thomas fire, the county had not conducted an assessment of countywide shelter capacity. She indicated that the Red Cross was the county's local government partner and the primary organization responsible for operating sheltering facilities, including identifying and developing shelter locations. However, without a capacity assessment, the county would not be able to determine whether it had adequate shelter space for its residents during a disaster.

The counties' approaches were challenged during the recent disasters. According to the chair of Sonoma's access and functional needs committee, during the Sonoma Complex Fires, the number of people with access and functional needs in shelters exceeded the county's original estimates and overwhelmed its capabilities. Similarly, the chief deputy director at Ventura stated that the Thomas Fire demonstrated that if a large-scale disaster affects the county again, it may not be able to adequately house all residents seeking shelter within its current list of shelters. She stated that Ventura was working with cities in the county to identify the current capacity of all shelters and that the county needs to be prepared to establish shelters on its own. Similarly, Butte's director of employment and social services indicated that the size and scope of the Camp Fire created challenges in promptly procuring an adequate number of accessible cots, toilets, and showers for all those in the shelters who needed them.

The Counties Did Not Adequately Prearrange Key Resources for Shelters

After a county identifies the resources it needs to make its shelters accessible, best practices recommend that it make arrangements with private providers to have those resources promptly available during a natural disaster. However, none of the three counties had conducted sufficient assessments of their resource needs or adequately prearranged agreements for obtaining equipment and supplies to ensure the accessibility of its shelters. Specifically, neither Sonoma nor Ventura had adequate prearranged agreements in place to acquire key sheltering resources. For example, Sonoma had an agreement for obtaining bulk pharmaceuticals and accessible toilets, but according to its procurement general services manager, it did not have agreements for obtaining accessible cots, showers, or durable medical equipment. The staff emergency manager at Ventura asserted that Ventura does have provider agreements for sheltering supplies. However, we reviewed the agreements that he provided and found that Ventura did not have agreements for key sheltering supplies, including accessible cots and showers. Ventura had an agreement for accessible toilets, but the agreement stated that it was only for scheduled events or events longer than 30 days, making it unlikely that Ventura could use the agreement during a disaster. Ventura's chief deputy director who oversees shelter operations stated that the county is working on obtaining a variety of agreements for sheltering supplies. She further stated that the county plans to conduct an equipment and supply assessment so that it can build supply portfolios to have a clear understanding of what equipment and supplies are located within the cities to increase efficiency of delivery and reduce duplicate purchases.

Staff at Sonoma and Ventura explained that during past disasters, the counties relied on the Red Cross as the primary provider to open, manage, and supply their evacuation shelters and that in the past, this approach had met the counties' needs. The Red Cross has a federal charter to provide relief across the country during natural disasters, including through the support of emergency shelters. However, FEMA's guidance on managing shelters states that local emergency managers and shelter planners—and not other entities—are responsible for ensuring that sheltering services and facilities are accessible. Further, if an emergency management agency relies solely on one source to provide essential emergency services, it risks discovering during a crisis that that agency will not be able to provide services. Because the Red Cross provides support during natural disasters throughout the nation, it may not always be able to immediately fully support local emergency shelters. For example, during the Thomas Fire in Ventura, the Red Cross was also operating shelters in response to a hurricane in Texas.

Among the three counties, Butte had prearranged the most agreements. Specifically, it had memorandums of understanding with more than 25 local health care providers to provide accessible cots, medical personnel, and equipment during emergencies, and it also had separate agreements for accessible toilets. Staff from Butte stated that these agreements allowed the county to more quickly obtain resources to accommodate people with access and functional needs following the Camp Fire. However, as of the time of our review, Butte still did not have an agreement in place to obtain accessible showers, which the county struggled to obtain in the aftermath of the fire. The director of employment and social services stated that there is a general shortage of accessible showers in the State but said that if there were a greater supply and if Butte were able to obtain such an agreement, it would have been able to procure those resources faster during a disaster event. According to the deputy director of Butte's general services department, Butte's regional transit authority was in the process of applying for a grant for a trailer with an accessible shower, which the transit authority was going to allow the county to use; however, because of a change in management staff, the grant application was not completed and the transit authority did not go forward with the grant.

Although each of the counties has taken some steps to improve their sheltering processes, none has fully implemented best practices for sheltering. Both Sonoma and Ventura have draft sheltering plans. Additionally, Sonoma's emergency coordinator stated that Sonoma had recently obtained grant funding to establish five sheltering supply trailers, which collectively will contain equipment and supplies for hundreds of individuals with access and functional needs, such as portable accessible showers. Sonoma's access and functional needs committee has also developed a list of shelter supplies that Sonoma should maintain. Both Sonoma and Ventura trained some of their staff to assess shelter residents during emergencies to identify unmet needs and request resources to meet them. Butte's director of employment and social services said she is working on developing additional and updated agreements for shelter resources and on obtaining updated information on the accessibility of the county's shelter locations to people with disabilities. Although the counties' efforts will likely improve their ability to operate shelters, until the counties more fully implement best practices related to sheltering, their ability to most effectively meet access and functional needs in those shelters may be hampered.

The Counties Had Not Adequately Planned To Establish Local Assistance Centers

In addition to shelters, counties can establish local assistance centers following natural disasters that enable individuals and families to easily access available disaster assistance programs and services. These services may include help requesting important documents, such as birth or marriage certificates, and help obtaining nutritional assistance, housing, and other necessities. The state and federal governments offer a variety of services to those affected by natural disasters—we list examples in Appendix A. Disaster survivors can access those services at a local assistance center, which is usually a single facility where they can meet with representatives from different federal, state, and local agencies. It is important that counties establish these centers as quickly as possible following disasters so that residents can begin receiving the assistance they need. Further, Cal OES guidance indicates several steps local jurisdictions should take to ensure that people with access and functional needs are aware of and can access the services at local assistance centers.

The counties' approaches to planning to operate local assistance centers varied. For example, before their recent wildfires, neither Butte nor Ventura had plans for establishing local assistance centers. Butte's director of employment and social services stated that Butte instead used Cal OES guidelines for establishing local assistance centers as its plan. In contrast, Sonoma had a plan that it called its local assistance center handbook, but the handbook did not contain adequate measures for ensuring that local assistance centers would be accessible to people with access and functional needs. For example, contrary to best practice, the handbook does not direct Sonoma's public information officer to notify the public about the availability of the local assistance center in languages other than English, nor does it direct the staff who establish the assistance center to consider proximity to public transportation—a consideration Cal OES advises local jurisdictions to make and which could be consequential for those who lack transportation. Despite having the handbook, the individuals tasked with opening the local assistance center did not use it because an emergency coordinator at Sonoma did not give it to them until after they had opened the center. Instead, those individuals used guidance from Cal OES to operate the local assistance center.

The planning and preparedness deficiencies at Sonoma and Ventura may have contributed to challenges that those counties faced in ensuring that sufficient resources were available to assist people with limited English proficiency at the local assistance centers they established following the recent wildfires. Ventura's human services agency supported the local assistance center, and in its after‑action review of the local assistance center, it noted that bilingual ambassadors was an area that could be improved. The chief deputy director explained that this observation in the after‑action report meant that its local assistance center needed more translation services for languages other than English. In a related issue, we reviewed materials that Sonoma provided to survivors who attended its local assistance center, and we found that Sonoma did not provide the materials in languages other than English, and the manager who oversaw the local assistance center confirmed that it had not done so. He also stated that when county staff recognized that the local assistance center needed translated signs, he put up handwritten signs.

Butte's approach to opening a local assistance center during the Camp Fire differed from Sonoma's and Ventura's. According to Butte's director of employment and social services, the county chose to open a disaster recovery center, in partnership with FEMA, which offers the same services and resources as a local assistance center. She explained that this meant FEMA was responsible for procuring the space for the center and providing equipment and supplies and that the county worked as a support partner.

Local assistance centers that are not fully accessible to people with access and functional needs can impede those people's ability to take advantage of available resources for helping them recover from natural disasters. Staff at all three counties acknowledged the issues we identified and stated that they will revise their plans or take other steps to prevent similar problems in the future. In late September 2019, Sonoma provided a revised local assistance handbook that contains specific direction for ensuring that the centers it establishes will be accessible to people with access and functional needs, including direction to provide multilingual local assistance center signs and translation services for people who are deaf and people who do not speak English. Additionally, in response to flooding in early 2019, Sonoma opened a local assistance center where it posted signs and provided materials in Spanish. By revising their plans for establishing local assistance centers to ensure that they are accessible to people with access and functional needs, the counties can better ensure that people with those needs can benefit from the disaster recovery services there.

The State Must Take a More Proactive Role in Ensuring That Local Jurisdictions Adequately Plan to Protect Their Communities During Natural Disasters

As we detail throughout this chapter, the counties we reviewed have significant gaps in their preparedness to protect and assist vulnerable populations in the event of natural disasters. The inadequate planning for individuals with access and functional needs that we found at Butte, Sonoma, and Ventura is consistent with our country's history of natural disasters disproportionately affecting those individuals. Further, some of the deficiencies that we found at the counties—such as not having evacuation plans or not issuing effective alert and warning messages—affect all of their residents, not just those with access and functional needs. California faces a future that experts predict will include more frequent natural disasters. At the same time, demographic changes in the State have resulted in an increased population of elderly residents. These factors indicate that the potential effects of being underprepared for natural disasters are growing. Therefore, it is critical that the State do more to ensure that local jurisdictions are as prepared as possible.

As we describe in the Introduction, the State recently invested $50 million to build resiliency in vulnerable communities. It awarded about $15.5 million of the funding to community organizations and cities and counties to help those entities develop more robust citizen emergency response efforts. However, none of the grant awards have directly funded local jurisdictions' efforts to develop emergency plans that ensure that they meet their communities' access and functional needs or that they involve representatives of groups with access and functional needs in their emergency planning processes.

Although recent changes to state law will likely improve planning efforts, the changes do not provide accountability for ensuring local jurisdictions develop effective emergency plans. Effective January 2017, state law requires cities and counties, upon the next update to their emergency plans, to integrate access and functional needs into the plans by addressing, at a minimum, how individuals with access and functional needs are served by emergency communications, emergency evacuation, and emergency sheltering. Further, recent changes to state law, effective January 2020, require cities and counties to include representatives of people with access and functional needs during the next update to their emergency plans to ensure that they integrate those needs into their plans. Another change, also effective January 2020, requires cities and counties to integrate cultural competence into their plans in the areas of emergency communications and evacuations, among others. However, the State continues to have a gap in accountability for ensuring that local jurisdictions engage in effective emergency planning. Unlike in California, state laws in Florida and Texas require each state's emergency management division to establish standards for and to periodically review local jurisdictions' emergency management plans. A similar requirement in California could direct Cal OES to review and provide feedback to local emergency management agencies on the extent to which their plans effectively incorporate emergency management best practices, especially related to protecting and assisting people with access and functional needs.

If Cal OES were to report the results of those reviews publicly, it would provide public accountability for local emergency management agencies. As the State's leader in emergency management, Cal OES is best positioned to provide the necessary expertise to conduct these reviews. It is also the appropriate entity to assist local jurisdictions in bringing their plans into alignment with best practices to ensure that they are best prepared to protect their communities.

The counties and Cal OES varied in their perspective about Cal OES oversight. Butte was agreeable to Cal OES conducting reviews of emergency plans; however, its county administrative officer expressed doubt that the county could modify its plans to meet the standards that Cal OES sets for these reviews without funding from the State. Similarly, Sonoma indicated that in order to meet the standards that Cal OES sets, the county would need funding from the State. Ventura's staff emergency manager stated that it would be helpful to have Cal OES review the county's emergency operations plan but not its supporting plans because there are far too many and he would not want such a review to inhibit the county's progress. Cal OES's acting deputy director of response operations shared that it already reviews emergency plans when counties and other local jurisdictions choose to share their plans with Cal OES's regional offices. He explained that the review is a crosswalk to ensure that all required structural elements of an effective emergency operations plan are incorporated in the counties' and local jurisdictions' plans. We reviewed the crosswalk that Cal OES uses to review local jurisdictions' plans and found that it does not incorporate a review of the extent that local jurisdictions incorporate best practices; rather, it reviews the extent to which the plan implements the State's emergency management system. The acting deputy director further noted that Cal OES was not currently staffed to perform statewide plan reviews, so any changes to its responsibility would also need to be accompanied by additional resources.



To ensure that local jurisdictions develop emergency plans that include adequate measures to protect and assist all people in their communities, including those with access and functional needs, the Legislature should require Cal OES to do the following:


To best prepare to protect and care for people with access and functional needs, the counties should revise their emergency plans by following the best practices that Figure 11 identifies. The counties should begin implementing these practices as soon as possible. By no later than March 2020, the counties should develop a schedule for completing updates to their respective emergency plans.

Figure 11
Emergency Planning Best Practices

A list of emergency planning best practices for preparing to account for individuals with access and functional needs in the areas of emergency plan development, alert and warning, evacuation, sheltering, and local assistance centers.

Source: Guidance from FEMA, Cal OES, and other governmental organizations.

To ensure that they maintain updated emergency plans that are consistent with current best practices, the counties should adopt ordinances establishing requirements for the frequency with which they must update their emergency plans and should set that frequency at no greater than five years.

To ensure that their emergency planning efforts more fully account for people with access and functional needs in the future, the counties should adopt county ordinances that require their county emergency managers to do the following during each update to their emergency plans:

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Chapter 2

Cal OES Has Not Provided Local Jurisdictions With Critical Guidance on Protecting Vulnerable Populations

Cal OES's mission is to protect lives and property, build the State's emergency response capabilities, and support communities for a resilient California. As a part of that mission, we expected that Cal OES would assist local jurisdictions in developing emergency plans that include effective strategies for protecting people with access and functional needs during natural disasters. However, Cal OES has not taken several important steps to provide that support. For example, it has not given local jurisdictions required guidance related to identifying people with access and functional needs and to evacuating these populations during natural disasters, despite state laws requiring it to do so. Further, it has not modeled best practices by involving people with access and functional needs in the development of key planning and guidance documents. Finally, Cal OES has not created and disseminated timely after‑action reports that would help local jurisdictions learn from others' successes and mistakes during the response to natural disasters. Cal OES's failures to provide critical guidance to local jurisdictions have impeded its ability to fulfill its mission to support local jurisdictions.

Cal OES Has Not Adequately Supported Local Jurisdictions in Their Planning to Assist People With Access and Functional Needs During Natural Disasters

State law makes Cal OES responsible for the State's emergency and disaster response services, including activities necessary to prevent and respond to the effects of disasters on people. Because of this assigned responsibility, we expected that Cal OES would be effectively supporting local jurisdictions in planning to protect the significant percentage of the population who are likely to have access or functional needs during an emergency. Specifically, we expected it to have provided resources to help local jurisdictions in planning, made those resources readily available, and involved representatives of people with access and functional needs in developing its guidance and in maintaining the State's emergency management system. However, as Figure 12 shows, Cal OES has not adequately done so. Because of these deficiencies, Cal OES has not done enough to fulfill its mission to protect lives and support communities' abilities to withstand and recover from natural disasters.

Figure 12
Cal OES Has Not Taken Key Steps to Support Local Jurisdictions in Planning to Meet Access and Functional Needs During Natural Disasters

An infographic showing the key steps that Cal OES has not taken to support local jurisdictions in planning to meet access and functional needs during natural disasters.

Source: FEMA best practices, state law, charters and meeting documentation for the Cal OES committees that develop and approve guidance, Cal OES planning guidance, the Cal OES website, and interviews with staff at Cal OES.

Despite the Requirements in State Law, Cal OES Has Not Provided Critical Guidance to Local Jurisdictions

Cal OES has not responded effectively to changes to state law that require it to provide support to local jurisdictions. In 2013, the Legislature amended state law to require Cal OES to update the state plan to include proposed best practices for local governments and nongovernmental entities in mobilizing and evacuating people with disabilities and others with access and functional needs. The amendment came because the Legislature found that too little of the state plan was dedicated to senior citizens and the needs of people with disabilities. However, Cal OES has not made these changes, and the state plan still contains no guidance on evacuating people with access and functional needs, nor does it direct local jurisdictions to any such existing guidance or best practices.

The manager of the unit at Cal OES responsible for updating the state plan asserted that Cal OES did not include these best practices because the state plan is a high-level framework meant to support statewide operations during an emergency. She explained that Cal OES decided to post the relevant evacuation best practices on its Office of Access and Functional Needs website instead. However, Cal OES did not notify the public or mention in the State plan that it decided to post these best practices elsewhere. Therefore, local jurisdictions that reviewed the State plan to find these best practices would have been unable to do so.

Further, although the Office of Access and Functional Needs' website does contain some guidance for mobilizing and evacuating individuals with access and functional needs, it does not direct local entities to perform the best practice of identifying their populations who might require evacuation assistance during an emergency. As we describe in the previous chapter, not identifying in advance which people within a community may need additional help in evacuating may result in an ineffective response during an emergency.

In addition, Cal OES has not fully complied with a state law related to the establishment of disaster registries, despite the fact that this law has been in effect for nearly three decades. Disaster registry programs are voluntary listings for which people with access and functional needs can sign up to be added to a list that first responders and others may use to provide alert and warning messages and to locate people to verify that they have evacuated. Since 1991 state law has required Cal OES to develop model guidelines for local jurisdictions that plan to develop disaster registry programs. Although Cal OES has released some guidance related to disaster registry programs, that guidance does not include all required elements. Specifically, state law directs Cal OES to publish guidance that includes recommendations for addressing known problems with the use of disaster registries, such as maintaining privacy for the people on the registry, as well as clarifying that the intent of the registry is not to provide immediate assistance during an emergency and that individuals must be prepared to be self-sufficient. However, the guidance that Cal OES has issued states that registries have proven unworkable, generally emphasizes concerns about registries, does not contain all of the information that state law requires, and provides little additional advice about how a local jurisdiction should manage a registry.

Cal OES's deputy director of planning, preparedness, and prevention acknowledged that Cal OES has not issued model guidelines in accordance with the law. She stated that the agency has not done so because staff at Cal OES consulted with local governments and stakeholders and determined that registries present significant challenges related to privacy and maintenance. However, by disregarding registries rather than providing the required guidelines, Cal OES has failed to follow state law and has not issued guidance that could benefit local jurisdictions that do choose to implement disaster registries. Of the three counties we reviewed as part of this audit, only Butte maintained such a registry. To the extent that Butte or any other county could have benefited from guidance on registry management, Cal OES has failed to fulfill its mission of supporting communities through collaboration with local jurisdictions.

Finally, Cal OES has not adequately supported local jurisdictions in ensuring that they can quickly issue translated alert and warning messages during emergencies. Effective January 2019, state law requires Cal OES to develop alert and warning guidance and to create a library of translated emergency notifications that it must develop after taking into consideration the two most commonly spoken languages in California other than English. According to census data, those languages are Spanish and Chinese languages, including Mandarin and Cantonese. The law also requires Cal OES to produce a translation style guide that includes a glossary of translated standard abbreviations used in emergency notifications (translation style guide). Cal OES issued alert and warning guidance in March 2019 and included examples of alert and warning messages in English as part of that guidance. The director of emergency management at Sonoma told us that he had expected Cal OES to provide translated message templates when it released this alert and warning guidance. However, at the time we began this audit, Cal OES had not yet developed the templates and provided no clear plan for complying with this provision of state law.

After we repeatedly asked Cal OES about its plan for developing the templates and translation style guide, Cal OES informed us at the end of September 2019 that it had completed a set of translated messages in Spanish, and in early October, it published translated messages in 17 other languages. Although Cal OES posted these messages and indicated that they were sample messages for use by local jurisdictions, they are marked by deficiencies. Most importantly, the translated messages will not be helpful to emergency managers who do not already speak these languages because Cal OES has not provided a crosswalk of the English and translated versions of the templates. As a result, the guidance provides no indication of what the messages are about for someone who does not speak, for instance, Chinese or Armenian, which greatly increases the risk that local jurisdictions will not use the templates or will use the wrong message template in an emergency situation.

Further, the sample messages that Cal OES developed are not templates that local jurisdictions can use to send messages specific to their circumstances. Rather, these sample messages are written and translated for very specific situations. For example, all three of Cal OES's sample translated shelter-in-place messages specify that residents must remain inside due to a hazardous materials release. Accordingly, without access to their own translation services, local jurisdictions would not be able to use this message to warn residents to shelter in place because of other hazards, such as flooding or an earthquake. Cal OES's translated messages stand in contrast to the templates Ventura developed: a variety of message templates in both English and Spanish for many potential hazards such as brush fires, smoke, and tsunamis.

Cal OES claimed it had also developed the translation style guide the law requires, but there are problems with the guide. In October, when it released the translated sample messages, Cal OES also released a foreign language style guide in English with glossaries of terms in English, Spanish, and Vietnamese. However, the terms that Cal OES translated do not concern specific threats that emergency managers could use to replace the sample message content. For example, as we discuss above, the sample messages included shelter-in-place orders specific to a hazardous materials release; therefore, if Cal OES had provided translated terms for other potential threats, such as wildfires, earthquakes, or floods, emergency managers could use these translations to amend the sample messages to fit their own circumstances. However, Cal OES did not include in its glossaries the translations for the words for wildfire, brush fire, earthquake, or flood. Rather, the glossaries of terms focuses predominantly on emergency management terminology—such as incident command system, mutual-aid agreement, and alert origination tool—and provides translations of those terms and their definitions. Finally, to the extent that Cal OES included useful terms in this style guide, it has still only provided translations in Spanish and Vietnamese—leaving untranslated the second most prevalent languages, Mandarin and Cantonese, and other languages commonly spoken in the State. These observations cause us to question the value of the glossaries to emergency managers who would attempt to use them to assist in issuing important emergency notifications.

Cal OES disagreed with our conclusion that it has not adequately supported local jurisdictions in the development of emergency plans that assist people with access and functional needs because it has not produced required guidance documents and tools. Staff at Cal OES pointed to other guidance it has produced to support local jurisdictions. We agree that the guidance that Cal OES has developed—such as the training course we discuss in the Introduction or the map of access and functional needs resources that it features on its website—can be useful as local jurisdictions enhance their planning for people with access and functional needs. However, the guidance we focused on during our review is important and required by state law. As we indicate in the Introduction and throughout Chapter 1, the areas of evacuation and alert and warning are of critical importance for all residents, especially those with access and functional needs who are more likely to need additional assistance or alternate methods of communication. Therefore, the lack of adequate guidance in these key areas is a critical deficiency in Cal OES's leadership. As a result of this deficiency, local jurisdictions with primary responsibility for responding to emergency situations are left without key guidance that the Legislature and the Governor intended to be available to assist them in protecting lives during emergencies.

Cal OES Has Not Ensured That Local Jurisdictions Can Locate Its Guidance Regarding Access and Functional Needs

Cal OES has developed some guidance and tools for local jurisdictions to use in their emergency planning, including their planning to meet access and functional needs; however, it has not made those resources easily available to the local jurisdictions. Cal OES's website includes a page that it refers to as its access and functional needs library. However, locating any specific guidance on the library page is challenging because it consists of a list of almost 250 links to different websites and documents. Many of the links have vague names—such as "Feeling Safe, Being Safe" and "Show Me Communication Board"—and no descriptions accompany the links explaining the content visitors should expect to find. Additionally, Cal OES does not indicate which guidance is most valuable for local jurisdictions, so they must sort through less relevant guidance, such as guidance directed at hospitals or polling places, to find the information they need.

The chief of Cal OES's Office of Access and Functional Needs (chief) acknowledged that the access and functional needs library could be improved so that local jurisdictions can more easily navigate it. He stated that Cal OES would seek a contract to restructure and improve the webpage, but he also noted that it has not done so because of resource limitations. The chief further noted that he conducts outreach events throughout the State to provide guidance to local jurisdictions and that no one has complained to him about the access and functional needs library being inoperable. Nonetheless, until Cal OES improves the main online resource it provides, local jurisdictions attempting to use the library will likely face challenges in locating the information that would be most useful to them. This lack of organization is particularly detrimental to jurisdictions with fewer resources and less time to devote to emergency planning.

Cal OES Has Not Modeled Best Practices by Including Individuals With Access and Functional Needs When Developing Guidance

As it provides assistance to local jurisdictions in effectively planning for emergencies, Cal OES has not followed a critical best practice: involving individuals with access and functional needs. As Chapter 1 describes, FEMA and other organizations state that to ensure that emergency plans adequately address access and functional needs, emergency planners should include individuals with such needs or their representatives in the emergency planning effort. In addition, state law requires that to the extent practicable Cal OES include representatives of people with specific types of disabilities on the committees it uses to issue guidance to local jurisdictions and to develop and approve the State's system for emergency management. As of July 2019, Cal OES had seven such committees, including a committee for developing alert and warning guidance and another for improving Cal OES's process for documenting in after-action reports the lessons learned during natural disasters. However, Cal OES has not adequately involved people with access and functional needs on any of these committees.

The documentation that Cal OES provided to us shows that rather than involving a diverse group of people with access and functional needs, it placed the same individual—the chief of its Office of Access and Functional Needs—on six of the seven committees (the charter for the final committee does not list an access and functional needs representative among the committee membership). Although the chief is Cal OES's subject matter expert regarding access and functional needs, he is not representative of all access and functional needs populations. As we previously discuss, access and functional needs encompasses many needs or challenges that individuals may have. Emergency planners must plan to meet each of these varying needs or challenges, and people who have these needs are best positioned to provide suggestions on how to address them. Despite the subject matter expertise that the chief possesses, he cannot provide the same depth of insight on specific access or functional needs as people with those needs or their representatives can provide.

The chief agreed that having multiple subject matter experts on access and functional needs would be beneficial and that planning is better when it includes a broader diversity of perspectives. According to the chief, the representation of access and functional needs on these committees was negatively affected when the committees began meeting less regularly because of more frequent emergencies that required Cal OES's attention and involvement. However, Cal OES did not include these representatives on the rosters for any of its more newly formed committees, making us question whether it has made a sufficient effort to include representatives with access and functional needs. For example, when it proposed members for the committee it created to develop the alert and warning guidance it published in March 2019, Cal OES did not include representatives of people with access and functional needs other than the chief. The chief noted the impracticality of ensuring that representatives of every possible access and functional need were included on every Cal OES committee and believed that effective representation of needs can happen through a smaller number of individuals. That perspective notwithstanding, state law is clear that Cal OES should strive to include persons with specific disabilities on these committees, and we believe that more full incorporation of the perspectives of individuals with access or functional needs would align Cal OES with best practices.

Given that communication is one of the key areas of emergency management requiring consideration of access and functional needs, the fact that Cal OES did not include a diverse set of individuals with such needs when developing its alert and warning guidance was a significant shortcoming. In fact, the inadequate representation of individuals with access and functional needs on Cal OES's alert and warning committee may have contributed to gaps we observed in the guidance that the committee developed. Cal OES issued the alert and warning guidelines after a change to state law that went into effect in January 2019. That change required Cal OES to develop guidelines for effectively notifying people with access and functional needs of emergencies. Such guidelines would reasonably address methods of alerting people who may, for example, be deaf, be blind, or have developmental disabilities. Although Cal OES's guidelines encourage local jurisdictions to make alert and warning messages accessible to people with those needs, they do not include strategies for doing so and instead list general considerations that jurisdictions should make. Had the committee included a diverse set of individuals with access and functional needs, those individuals could have provided perspective and insight on specific practices for effectively communicating emergency messages.

Cal OES's failure to ensure the diversity of its planning groups may have a detrimental effect on local jurisdictions. As the State's leader in emergency management, it is critically important that Cal OES set the tone for local jurisdictions by following emergency planning best practices, including those related to supporting individuals with access and functional needs. Individuals from local jurisdictions serve on some of Cal OES's committees and can therefore observe the extent to which Cal OES involves representatives of people with access and functional needs in these committees. When Cal OES does not include diverse representation, the risk is higher that local jurisdictions will not believe that the practice is worthwhile for their own planning efforts. Further, local jurisdictions should be able to rely on the guidance that Cal OES provides regarding what to include in their emergency plans. If Cal OES's guidance does not fully address access and functional needs, the local jurisdictions' plans—like those in the three counties we reviewed—are also less likely to do so.

Cal OES Has Not Used After-Action Reports to Share Lessons Learned From Recent Disasters, Even Though Doing So Could Aid Local Jurisdictions' Planning Efforts

Cal OES is uniquely positioned to observe, collect, and disseminate information about lessons learned during natural disasters across the State. As the agency tasked with coordinating state resources and mutual aid in response to those jurisdictions requesting assistance during an emergency, Cal OES has the opportunity to observe those jurisdictions' successes and struggles during natural disasters. It can identify problems caused by gaps in the jurisdictions' emergency preparedness and determine how frequently similar issues arise across jurisdictions.

Further, implicit in Cal OES's mission to protect lives, build capabilities, and support communities is a responsibility to identify and take proactive steps to correct problems in emergency management that may jeopardize the lives of residents, including those with access and functional needs. Although Cal OES does not bear responsibility for local jurisdictions' shortcomings, it can play a critical role in helping local jurisdictions avoid the mistakes of others. In fact, for each declared disaster, state law requires Cal OES, in cooperation with other state and local agencies, to complete an after-action report, which includes a review of the public safety response actions. Cal OES completes these after‑action reports in part based on a review of after-action reports that local jurisdictions complete and submit to Cal OES. In addition, the law requires Cal OES to make these reports available to all interested emergency management and public safety organizations. Therefore, the preparation of these reports presents Cal OES with a prime opportunity to share lessons learned and suggest corrective actions throughout the State. However, as Figure 13 shows, weaknesses in Cal OES's after-action report process have prevented it from sharing valuable information in this manner.

Perhaps most importantly, Cal OES has not completed its after‑action reports in a timely manner. State law requires Cal OES to complete after-action reports within 120 days after a disaster. However, in a January 2019 meeting with Cal OES's state emergency system advisory board, the project manager responsible for improving after-action reporting at Cal OES shared with Cal OES's advisory board and its director that Cal OES has never completed after-action reports on time. From January 2014 through December 2018, there were 65 proclamations of natural disasters in the State for which Cal OES should have completed after-action reports. However, Cal OES has not completed after-action reports for the disasters associated with 57 of these proclamations. At the time of our review, the most recent disaster for which Cal OES had completed an after-action report occurred in February 2015, and it did not complete that report until May 2019—more than four years later. During those four years, numerous natural disasters occurred, including several of the largest and most destructive wildfires in California's history. As a result, multiple local jurisdictions have provided their own after-action reports from these disasters to Cal OES, and Cal OES could have used them to write and broadly disseminate an after-action report describing the lessons learned from those disasters. However, Cal OES has not distributed after‑action reports from any of those events.

Figure 13
Cal OES Has Not Shared After-Action Reports That Could Have Strengthened Disaster Response

An infographic showing that Cal OES has not shared after-action reports that could have strengthened disaster response.

Source: Cal OES after-action report documents and interviews with staff at Cal OES.

The potential value that one jurisdiction could gain from learning about another's errors during emergency planning or response makes Cal OES's failure to complete timely after-action reports a serious concern. For example, as we discuss in Chapter 1, Sonoma and Ventura did not issue messages directing people to evacuate in languages other than English during the 2017 fires we reviewed. Had Cal OES issued after-action reports related to these two disasters, we would have expected the reports to include a review of the use of English-only alert and warning messages due to the critical nature of communicating with all residents. In fact, each county provided Cal OES with its own after-action report that identified the trouble it had communicating with individuals who did not speak English. However, Cal OES has yet to issue after-action reports for these disasters. Subsequently, during the response to the Camp Fire in 2018, Butte also did not issue alert and warning messages in any language other than English. By sharing lessons learned from these natural disasters in a timely manner, Cal OES could help other local jurisdictions avoid this same mistake in future disasters.

In addition, by not issuing after-action reports, Cal OES has missed an opportunity to educate local jurisdictions about effective strategies that other local jurisdictions have employed during natural disasters. For example, during the December 2017 Lilac Fire, San Diego County (San Diego) used a specially trained team of Spanish language translators from various county departments to staff its county information center—which, during the time of the incident, was coordinating press conferences and posting information about the disaster online. In the after-action report that San Diego submitted to Cal OES, it reported that this team of translators increased the county's ability to provide emergency information in Spanish. The effectiveness of this strategy could aid other counties seeking ways to improve their ability to communicate with people with limited English proficiency during natural disasters. However, as of October 2019, nearly two years later, Cal OES has not issued an after-action report for the Lilac Fire, which could have informed other local jurisdictions about San Diego's effective use of a team of translators.

Cal OES has not set firm standards for completing after-action reports. Although state law requires it to complete the reports within 120 days, Cal OES shared with us that the date an incident is closed—which it believes begins the 120-day period—is not well defined. Despite this perspective, Cal OES has not taken action to better define that date, even though the minutes for the meetings of its after-action reporting committee show that committee members have acknowledged the need to do so. Given that the law requiring Cal OES to complete these reports became effective in January 1993, Cal OES has had more than enough time to correct any lack of clarity that exists in the required time frames for its completion of after-action reports, so we question the urgency of its efforts to produce those reports in a timely manner.

The branch chief who oversees the division responsible for creating after-action reports stated that some local jurisdictions involved in natural disasters do not submit their after-action reports to Cal OES and that Cal OES begins compiling its after-action report when all of the pertinent local agencies have submitted their required documentation. However, multiple local jurisdictions have already submitted their reports to Cal OES, and it seems imprudent for Cal OES to delay after-action reports while it waits for the remaining jurisdictions to submit their reports. Given the benefit that sharing lessons can provide to local jurisdictions in improving disaster response, and the devastating effects that mistakes can produce, Cal OES's dissemination of those lessons in a timely fashion is critically important. Therefore, Cal OES should not delay issuing after-action reports because some local jurisdictions have not yet submitted their reports. The branch chief agreed that the process must become timelier to ensure that Cal OES captures and disseminates lessons learned as quickly as possible. In March 2019 Cal OES revised its process for collecting after-action reports from local jurisdictions to require only the legally mandated information related to the State's emergency management system and to allow local jurisdictions to submit their responses through an online portal. The branch chief explained that streamlining and shortening the number of questions will enable the after-action process to be timelier and to meet requirements. However, as of October 2019, Cal OES informed us that it has not issued any after‑action reports using this process.

Even when Cal OES does complete after-action reports, it does not widely disseminate them or make them easily accessible to local jurisdictions. As we describe above, state law requires Cal OES to make its after-action reports available to all interested public safety and emergency management organizations. To achieve the greatest benefit from these reports, we expected Cal OES to publish them, likely by distributing them to local emergency managers or posting them on its website. Doing so would allow emergency managers in all local jurisdictions to quickly access the reports to learn about ways they can improve their emergency plans, response, and recovery. However, although Cal OES meeting minutes show that in June 2018 it discussed making reports available publicly, Cal OES told us during our audit that it requires local jurisdictions to request these reports. By making local jurisdictions request after‑action reports rather than broadly disseminating them, Cal OES limits the number of local jurisdictions that can benefit from the lessons that those reports contain.

Cal OES explained that it does not share its after-action reports publicly because they contain sensitive information. However, Cal OES could distribute lessons learned without divulging sensitive or confidential information about the natural disasters under review. It could, for example, publish an annual report summarizing new or successful emergency response strategies, problems that occurred during incidents over the previous year, and recommendations for how to prevent them. It could also redact the sensitive or confidential information before publication.

Cal OES believed that it effectively shares lessons learned through alternate means besides the after-action reports. The chief of Cal OES's emergency response section stated that Cal OES shares lessons learned from natural disasters verbally at mutual aid regional advisory committee meetings, which, according to Cal OES documentation, allow local jurisdictions to be informed of the latest information on emergency management and on the State's emergency management system. However, we reviewed meeting minutes and agendas for those meetings and found that although the minutes stated that some local jurisdictions shared lessons learned during those meetings, several local jurisdictions did not attend the meetings, meaning that they would not have benefited from those discussions. Similarly, although the chief asserted that he presents lessons learned related to meeting access and functional needs when he attends functions and events throughout the State, those lessons could only benefit the local jurisdictions that attend the functions he visits and the chief cannot reasonably visit every local jurisdiction in the State each year. Because it has not widely publicized lessons learned from recent disasters, through after‑action reports or any other means, Cal OES has failed to broadly distribute information that could help local jurisdictions across the State learn from the experiences of others and improve their ability to effectively respond to natural disasters.



To ensure that, as the leader of emergency response efforts in California, Cal OES meets its responsibility to provide local jurisdictions with critical support in planning to meet access and functional needs of the population during natural disasters, the Legislature should require Cal OES to do the following:


To ensure that it fulfills its responsibilities under state law, Cal OES should, by no later than June 2020, issue the guidance that state law requires it to produce related to access and functional needs, including guidance related to establishing disaster registries and guidance on evacuating people with access and functional needs.

To ensure that it adequately equips local jurisdictions to send alert and warning messages in languages that their residents will easily understand, Cal OES should do the following:

To improve local jurisdictions' ability to quickly retrieve guidance and resources related to planning to meet access and functional needs during natural disasters, Cal OES should make its emergency planning guidance and resources easily available through restructuring and improving its access and functional needs library webpage by April 2020.

We conducted this audit under the authority vested in the California State Auditor by Government Code 8543 et seq. and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the Scope and Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

California State Auditor

December 5, 2019

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