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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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Butte County

October 22, 2019

Elaine M. Howle
California State Auditor
621 Capital Mall, Suite 1200
Sacramento, CA 95814

RE: Butte County Response to the State Auditor's Report on Emergency Planning

Dear Ms. Howle:


Butte County ("County") appreciates the Legislature's interest in emergency planning in counties recently struck by large disasters, as well as the State's work in auditing Butte County's planning documents and emergency operations plans based on FEMA and CalOES guidelines and best practices and providing recommendations for improvement. In reality, most of FEMA's guidelines and best practices do not take into account large-scale, catastrophic wildfires in counties with limited financial and public safety resources. FEMA's guidance has historically focused on hurricanes and flooding, which allow for advanced notice and planning. Wildfires happen with no notice, unlike hurricanes and floods. The County understands that new regulations, guidelines, and best practices for devastating wildfires experienced by many California counties in the past two years, will be published in the future.


The audit report ("report") reflects the State Auditor's responsibility to cast a critical eye on matters it is charged with reviewing. The analysis highlights areas where improvements can be made. The County strives to improve response efforts after every disaster, and the recommendations will be considered along with input from other valued partners. The County is already implementing, or began implementing after the Camp Fire, many of the protocols regarding alerts, warnings and evacuations that are called out in the report. For the practices not already implemented and that are appropriate for Butte County, the County intends to implement them over time as resources become available.

General Response


It is important to define the structure for emergency response in Butte County to provide context to the report, as every county in California is structured differently to meet its individual needs.


It is also important to understand the order of magnitude and speed of the Camp Fire, a fire so devastating and fast that no plan could adequately address it. To put the fire in perspective, 83,000 acres were burned in the first 15 hours. On average that is 5,533 acres every hour, 92 acres every minute, or 1.5 acres every second. Within 75 minutes of the fire first being reported, there were spot fires on the eastern side of Paradise which is eight (8) miles away from the origination of the fire. Within another 60 minutes the fire had progressed halfway through the Town of Paradise. The speed of this fire overwhelmed all first responders and was unprecedented in California in its destruction. Due to the extreme chaos, the speed of the fire, and the loss of power, landlines, Internet connections, and cellular networks in the area, along with downed power lines, poles, and trees, navigating the area of Paradise was extremely difficult and dangerous for the public evacuating and for first responders. Communications were near impossible due to destroyed and damaged infrastructure, loss of power, and thick smoke. As evacuation routes became impassable and vehicles caught fire, sheltering in place became a necessity. Bodies of water and open areas such as parking lots and helipads saved many lives.

Wildfires are a danger throughout California, and the amount of planning and mitigation that is needed to be ready for a catastrophic fire like the Camp Fire far exceeds available local resources. The California Office of Emergency Services (CalOES) exists to support local government when it lacks adequate resources to respond. The State's mutual aid system is in place to obtain the resources needed on behalf of the impacted jurisdiction. No jurisdiction in California has sufficient resources for a catastrophic and large scale disaster like the Camp Fire.


The County agrees that plans serve an important purpose, and that training and practicing execution of the plans assists in identifying whether the theories in the plan are executable in reality. Butte County knows this too well as it has experienced more disasters than most counties. Ideally, all County planning documents would be updated on a regular basis. Unfortunately, the County lacks the resources to update all of its plans as often as it desires, as it has been faced with one disaster after another in recent years. Even though plans are not updated frequently, Butte County is better prepared than most California counties for future natural disasters due to its extensive experience over the past decade. Residents are not at a greater risk just because the County has not had the resources to thoroughly document these efforts.


Planning for wildfires is complicated. Wildfires have erratic behavior, and depending upon conditions they can move rapidly, well beyond the speed of humans, vehicles and even communication transmission. During wildfires, decisions must be made in the moment and emergency response must be nimble enough to adjust to changing circumstances. Though the report appears to make planning more important than response, the County knows from decades of experience in disasters that planning is helpful, but is not the only indicator of success in responding to disasters. Effective emergency response depends on training, experience, and the ability to make decisions under critical and fast-moving circumstances; something the County is proud to say it has done well.

The County concurs that plans have not been updated. There are two major factors that contribute to the lack of updates: 1) the impacts of the Great Recession on the County's financial and staffing resources since 2009-10 and 2) multiple disasters since 2016 – eleven disasters consolidated into eight local declarations (four of the eight included Presidential declarations and seven of the eight included State declarations). The County's plan, once the effects of the Great Recession lessened, was to update its emergency plans in 2017, but responding to disasters became a priority over updating plans. The work required of staff does not end once emergency response is over. Recovery efforts often require more time and resources. The amount of administrative reporting, document management, and tracking that is required for federal and State assistance is tremendous. The staffs responsible for updating plans have been required to focus on responding to disasters and obtaining reimbursement for the County, which has been a continuous cycle since the middle of 2016. The County would welcome financial and technical assistance from the State to update County planning documents in the future.


The County does not concur with the statement that lack of documentation and updated plans, and not following all best practices for planning, equates to not being prepared or having inadequate response and recovery efforts. Unfortunately, due a lack of County documentation, the report does not discuss or recognize the extensive planning, training, and community drills that have been done by Butte County over the past decade. The County provides many examples of excellent planning efforts and process improvements that have been put in place over the years, and as recently as post-Camp Fire, in Exhibit A to this response. The County does appreciate the report's recognition of the many remarkable efforts and even heroic acts by many during the Camp Fire.


The timing of the report is especially unfortunate, as Butte County and its residents are still in the midst of emergency response and recovery, and have yet to fully address the trauma felt by its residents. The report's timing caused additional burden as County staff had to divert their time to accommodate the audit and prepare this response, in place of providing vital services to residents. The County recommends that future reports on large and traumatic events be timed further out from the event to avoid further traumatizing disaster survivors and workers, who in the case of the Camp Fire are often one in the same. The County also suggests that the State Auditor's Office considers providing adequate time for jurisdictions to review and respond to audit reports. A few hours for review and five working days for response are especially difficult for a jurisdiction in the midst of recovery efforts from a catastrophic event.


Provided below are the County's responses to the recommendations in the published report. The County understands the purpose of the audit was to review emergency planning efforts, though it appears to have expanded its scope to include discussing response efforts during the Camp Fire and drawing conclusions based on limited information from interviews with a handful of County staff and some local partners over a short period of time. Given sufficient resources and fewer disasters, the County would have updated plans. The County does not agree with statements that the County does not preplan to obtain resources needed in a disaster because it doesn't have signed agreements in place. It is important to note that no amount of documented plans and signed agreements would change the lack of availability of resources in the County and surrounding areas due to the non-urban nature of Northern California, or throughout the State when multiple disasters are taking place simultaneously in California or the nation.


The report contains recommendations for the Legislature to place additional requirements on CalOES. The County would welcome the increased participation by CalOES in assisting with and reviewing local emergency plans. The County stresses that financial and technical resources for under-resourced counties are urgently needed to assist with planning efforts, though.

Recommendations for Butte County:

  1. Update emergency plans by following best practices provided in Figure 11 in the report, as soon as possible, and should develop a schedule for completing updates by no later than March 2020.

    Butte County agrees that its emergency plans need to be updated, and not just for individuals with access and functional needs. Butte County has been planning for such an update since 2016. Unfortunately, the County has not had the financial or staffing resources to begin an update due to multiple disasters beginning in the middle of 2016 (floods, wildfires, Spillway Incident, PG&E planned power shutoffs), as well as the impact the Great Recession had on the County's available financial and human resources. The same staffs that are responsible for emergency planning are also responsible for response and recovery. Until the County has completed the Camp Fire response and recovery, which could be years, it is unable to take on any additional duties without additional financial and staffing resources. Fire debris removal, hazard tree removal, housing, and financial survival are the County's focus at this time. The County will work on a schedule for updating plans, though updates will most likely not be completed in 2020.

    In addressing the recommendations in Figure 11, which are specific to access and functional needs populations and required by State law after January 2020, the County's process will include the following in its next plan update.

    Emergency Plan Development

    • A diverse planning team with additional focus on the access and functional needs population, and interested community-based organizations that serve the population.
    • Continued utilization of the data historically utilized by the County including Census data, data from County health and human services departments and community organizations, PG&E medical baseline data, and CalOES resources, to assess needs.
    • Emergency plans will be updated as resources are available, with a goal of every five years.

    Alert and Warning

    • The Sheriff's Office completed an updated alert and warning plan in October 2019.
    • The Sheriff's Office completed creation of pre-scripted messages in October 2019.


    • The County has an all-hazard mitigation plan, and as resources are available, will update elements that do not reflect current practices and conditions.
    • The County has access to multiple data sources (Census, medical baseline, Special Needs Awareness Program (SNAP) registry, etc.) regarding people who might need evacuation assistance. The County utilizes that data for pre-planning and during every disaster. Real time data and mapping is required during any disaster, not data that is contained in a plan from a point-in-time.
    • Though an agreement is not necessary with the local transit agency, as the County is a member of the agency and can access buses whenever requested during an emergency, the County will request a formal agreement with BCAG. The County will also request a formal agreement with the Butte County Office of Education and local school districts for use of school buses, though the resources have been used in past disasters without an agreement. Ambulance transportation is accessed through the State and the mutual aid process.


    • The County has an established sheltering plan and assessments of shelter facilities that provide details on which facilities can support access and functional needs individuals. Butte County will update the plans as necessary and as resources are available.
    • The County has historical data from multiple disasters that provides a good assessment of how many people may seek shelter during disasters, as well as how many have access and functional needs and the resources needed to support them. In addition, the County will continue to use the Bay Area Urban Areas Security Initiative shelter planning tool that calculates shelter estimations based on population to plan for needed resources. The tool incorporates the best practices from FEMA and CalOES.
    • The County will continue developing agreements with vendors, where equipment and resources are available in the area. For equipment and resources not available in the area, the County will continue to depend on the State to provide the resources.

    Local Assistance Centers

    • Butte County will continue to utilize the best practice guidelines established by CalOES and incorporate them into the County's Emergency Operations Plan. When a Local Assistance Center is opened, Butte County will continue to ensure that it is accessible and that communication services are provided for those with limited English proficiency.
  2. Butte should adopt ordinances establishing requirements for the frequency with which it must update its emergency plans and should set that frequency to no greater than five years.

    The County will consider adopting an ordinance as recommended, though it will have a caveat that it is a goal and not a requirement and will recognize that future disasters or competing priorities for limited resources may make meeting the frequency goal difficult. The County will not hold people accountable for a standard that cannot be met due to circumstances out of the control of the responsible party.

  3. Butte should adopt county ordinances that require its county emergency manger to do the following during each update of its emergency plan.

    • Adhere to the best practices and guidance that FEMA, CalOES, and other relevant authorities have issued when planning to protect people with access and functional needs.
    • Report publicly to the Board of Supervisors during emergency planning about the steps it has taken to address access and functional needs.
    • Consult periodically with a committee of community groups that represent people with a variety of access and function needs and require that representatives of the community group committee present to the Board of Supervisors its adequacy of the emergency plans.

    The County strives to follows best practices for any type of planning. The County will convene a committee representing the populations described above, and hold periodic meetings for input on emergency plans, once there are financial and staff resources available for planning purposes. Staff will provide written updates to the Board of Supervisors during planning processes and will post the updates to the County's Office of Emergency Management website for the public. The County will consider the best tool for the participants to provide feedback on the plan to the Board of Supervisors.

The County expresses sincere appreciation to the Legislature for its interest in this important topic. The report underscores that under-resourced counties, such as Butte, need resources and technical assistance from the State. The County also thanks the State Auditor's staff for their professionalism and their efforts to accommodate challenging schedules as they attempted to review a very complex topic in a short amount of time. The County appreciates that some discussions were difficult for those who have not been through such a devastating disaster, and want to recognize that the State Auditor's staff are now a piece of the Camp Fire history.


Shari McCracken
Chief Administrative Officer
  Kory L. Honea

Exhibit A


As the format of the report carries common themes throughout the findings, the County has chosen to organize specific information by those common areas, instead of following the order of the report. Provided below is detail behind each of the common areas that may be of interest to some readers. It is provided to acknowledge the hard work of the County and its partners, and recognized as County assertions where documentation was not available to support it for purposes of the report.

Emergency Planning

The report asserts that Butte County has not adequately followed best practices for emergency planning. The foundation of this assumption appears to be based on the fact that Butte County does not have an updated Emergency Operations Plan or clear documentation of all of its emergency response procedures and practices, which the County does not dispute. The finding does not take into account historical and current planning efforts by the County that have not been documented in a formal plan.

Butte County has collaborated extensively with stakeholders including CAL FIRE, California Highway Patrol (CHP), local law enforcement agencies, local emergency service providers, community organizations, Red Cross, CalOES and other State and federal agencies to develop protocols and practices for the response to emergency situations. Despite the fact that these established protocols and practices have not yet been codified in a single source document, they are part of Butte County's overall strategy to manage disasters. The protocols and practices have served the County well through multiple disasters and through after action review processes are improved upon each time the County faces a disaster and learns new lessons. The County appreciates that the report acknowledged that the County does have some updated response practices, even though they are not incorporated into a written plan.

Butte County has multiple sources of information on the demographics of its communities such as Census data, the Butte County Public Health Department's Community Health Assessment, supported living and health facility lists, and eligibility and client data from the Butte County Department of Employment and Social Services and other local service providers. Though it may not all be incorporated into a central plan, the County is aware of the facilities that house individuals with access and functional needs in its communities, as well as individuals living on their own. The Butte County Department of Employment and Social Services (DESS) maintains a database of people with access and functional needs. The database, as well as PG&E medical baseline customer data, is used for multiple purposes during disasters to reach out and communicate with individuals that might need assistance.

Though the County's All-Hazard Evacuation Plan has not been updated since 2011, it represents an incredible amount of effort and useful information to support disaster response. As part of the planning efforts, the Sheriff's Office worked collaboratively with Butte County Fire, Paradise Fire, and CAL FIRE to identify zones in Oroville, Paradise, Magalia and other foothill communities to better facilitate evacuations of those areas, prior to the Camp Fire. Maps of those areas with evacuation routes were created and distributed to residents to help them be better prepared. Drills and training regarding the evacuation plans were held with community members, the plans and maps are posted on the County's website, and copies of plans and maps were provided to local fire safe councils to share. The Sheriff's Office has a close working relationship with Butte County Fire, Paradise Fire, CAL FIRE, and CHP and has developed sound evacuation coordination procedures for emergencies. Butte County, the Town of Paradise and CHP, developed contraflow traffic plans for evacuation routes out of Paradise and Magalia well before the Camp Fire, in anticipation of evacuations in those areas. Various types of traffic plans have been implemented in real life incidents, multiple times each year for the past several years throughout the County.

Planning for Adequate Resources

Butte County is aware of the needs of its residents with access and functional needs due to frequent disaster responses and by the nature of the day-to-day services the County provides through many of its programs, especially health and human services programs. The report specifically calls out evacuating and sheltering people and states that Butte County has not fully ensured the availability of critical resources that would be needed during a disaster. The County agrees it does not have formal agreements in place, but must disagree with the assessment that resources are not available as the County has adequately coordinated transportation and sheltering through multiple disasters.

Regarding transportation for access and functional needs populations, the information in the database referenced previously is shared with the Sheriff's Office communications center so that in the event of evacuations Sheriff's Office dispatchers, if possible, can identify locations of people with access and functional needs. Once identified, first responders can respond to those locations to evacuate and assist the individuals. In addition, the Sheriff's Office and the Office of Emergency Management have pre-arrangements with the Butte County Association of Governments (BCAG), of which Butte County is a member, to provide buses and paratransit buses for evacuations. The resources may be ordered by the Sheriff's Office, or through the Emergency Operations Center, whichever is most expedient. In addition to County-provided transportation, individuals have the ability to call 2-1-1 to request assistance on their own, as BCAG and 2-1-1 have an agreement regarding paratransit resources. Ambulances for evacuating medically fragile individuals are ordered through the State's mutual aid process, as there are a limited number of ambulances locally. The State's mutual aid system, though not fully discussed in the analysis, is a key resource for all California counties in disasters.

The County agrees that it did not have adequate resources to evacuate all of the individuals with access and functional needs from the Camp Fire, as the rural road networks, the speed of the fire, and the devastation it was causing made it impossible to get enough resources into the area to remove every person. The assertion demonstrates the report's recognition of the unprecedented nature of the most catastrophic wildfire in California history.

A statement in the report requires clarification. The County does not wait to locate transportation during an emergency. It is well aware of the available resources. It is accurate to state that transportation is requested during disasters, as it is not possible to pre-order transportation prior to a disaster like a wildfire. During disasters, BCAG is notified as soon as the Emergency Operations Center is activated, and a request to dispatch appropriate transportation is made once the Sheriff's Office provides the location for staging. The County is aware that BCAG has sufficient buses for smaller events similar to the fires in 2017, and that it does not have sufficient buses for larger events as demonstrated during the 2017 Spillway Incident. Once BCAG resources are exhausted, the County requests support from the local schools. Butte County is not a large, urban county, so there are not multiple transit agencies or private transit services to contract with as you might find in urban areas like the Bay Area or Los Angeles.

Statements that the County should have agreements with vendors for all of the resources needed to shelter access and functional needs populations is not realistic. The County has agreements for available resources in the area, and depends upon the State to assist in procuring equipment and resources the County cannot. The County has recommended to both CalOES and FEMA that they consider regional caches of items such as ADA bathrooms, showers, and cots, as the length of time it takes for the State or federal governments to get such resources is problematic.

Adequate Warnings and Alerts

The County notes the assertion in the report that it did not prepare adequately to warn residents of danger from wildfires. That assertion does not take into account the complexities inherent with issuing alerts in "no-notice" events that almost immediately overwhelm the capacity of first responders and the systems in place to issue emergency notifications. It also does not take into account the County's efforts to provide alerts and warnings over and above the use of the CodeRED Alert Systems (CodeRED) to issue evacuation orders during the Camp Fire.

That assertion appears to be based solely on the fact that the first several messages sent through CodeRED did not incorporate Wireless Emergency Alerts (WEA) and Emergency Alert System (EAS) messages through the Integrated Public Alert and Warning System (IPAWS), which was initially a product of the chaotic conditions under which the sole staff member available at that time to send messages, was operating under. As the day progressed and a better understanding of the situation was developed, the staff member attempted to issue WEA/EAS messages concurrently with CodeRED messages. Those WEA/EAS messages were not successful. When that was learned, BCSO worked with CodeRED to issue subsequent WEA/EAS messages. (BCSO continues to work with CodeRED to understand the cause of the initial breakdown and we have since developed a protocol wherein emergency alerts are sent through CodeRED and a duplicate message is sent through IPAWS).

It is important to understand that a disaster the size of the Camp Fire is beyond the staffing capacity of most organizations, as agencies must staff to the norm and not to extreme circumstances. Under the circumstances of a normal disaster, staff would not have been immediately overwhelmed. The report does not acknowledge that the County initiated messaging to landlines in the affected area, in partnership with AT&T. Also, absent in the discussion is Voice over Internet Protocol (VoIP), which is the communication resource many foothill residents use due to lack of cell service availability. VoIP does not work when infrastructure is destroyed or power is out. In general, any technology-based alert systems, including WEA, EAS, and CodeRED, became useless as cell towers and infrastructure are destroyed quickly and power is cut off. This is evident in the rapidly decreasing delivery percentages illustrated in the Camp Fire notification lists. As the fire progressed and infrastructure failed, the percentages of successful notifications plummeted.

Overall, the findings in the report illustrate the frailty of any alert and warning system that relies solely upon the wireless network to convey messages. Butte County recognized that frailty years ago and as a result developed other methods of communicating emergency information to impacted communities. During the Camp Fire, Butte County also disseminated information to its social media sites, websites and traditional media. Local news channels began broadcasting about the fire and the evacuations immediately. First responders used sirens to alert people while doing door-to-door notifications. First responders used public announcement systems from their vehicles. All of these methods of alerting and warning the public are in accordance with FEMA and CalOES best practices. The County utilized numerous resources to warn residents before and during the Camp Fire. There is no FEMA best practice that will provide for broad notifications during a catastrophic fire storm as was experienced during the Camp Fire.

Butte County did not use template messaging during the Camp Fire, in part because templates had not yet been created by the State. In March 2019, 4 months after the Camp Fire, Cal OES released their Alert and Warning Guidelines. In October 2019, Cal OES released their library of messaging templates. The Sheriff's Office has since developed alert and warning guidelines and message templates in English, Spanish and Hmong, in compliance with the State's guidance. Important to note, the best practices referred to in the report do not take into account the inherent limitations of the WEA system with regard to its 90 character limitation. It is very challenging to convey a threat and the desired response in 90 characters, which is exacerbated when messaging in languages other than English, especially Hmong, as 90 characters cannot always accommodate translated messages.

According to the California State Warning Plan, "Current common practice across all warning systems is to approach multilingual alerting on a best effort basis, but not to delay transmission of English language warning messages while multilingual translations are prepared." Due to not having translation capabilities immediately available and the rapid spread of the Camp Fire necessitating multiple notifications, the County sent out alert and warning notifications in English.

The report states that because the Sheriff's Office did not identify messages as coming from the County it did not follow best practices, and the messages may not have been trusted by the public. However, the combination of the messages, the first responders ascending into Paradise and Magalia with lights and sirens, the black smoke that was overtaking the Town of Paradise, the social media posts released by the County and Town, public social media posts, and news coverage, made it abundantly clear that the area was in imminent danger and the County was warning people to evacuate.

Access and Functional Needs

The report states that the County's Special Needs Awareness Program (SNAP) registry only contains IHSS clients. The SNAP registry includes IHSS plus any individuals that self-identify as needing assistance. In addition, the County has access to PG&E's medical baseline data to further enhance the registry. The County does continuous outreach to individuals and service providers to ensure individuals who might need assistance are included on the registry.

The County has coordinated with groups representing access and functional needs populations and will expand that outreach in the future, as the report states there are additional groups that are interested in participating.


The County has been extremely proactive in working with communities at risk of wildfires and creating evacuations plans. Community evacuation plans were mailed out to all residents as part of the "Ready, Set, Go" campaign in 2016, and extra copies were provided to fire safe councils in numerous communities, including the Town of Paradise. The plans include information on how people can identify which zone they live in. As the County has learned over the years, it takes multiple methods of providing information to reach as much of the public as possible and there is always the potential for not being able to reach everyone. Butte County and the Town of Paradise have worked to educate the public on the zone they live in, but there will always be some portion of the public who will not know what the plan is.

The County is working with other transportation and law enforcement partners to address the traffic congestion experienced in the Camp Fire, by planning to initiate contra flow at points further out from the event. As the County learned, contra flow is an excellent tool until it hits roads that are not set for contra flow.

The report does not recognize that sheltering in place is an emergency option when evacuation routes are not viable. Many lives were saved by jumping into a lake or congregating in open parking lots with minimal vegetation surrounding them. Though this may not be designated a best practice, it may be a reality in rural communities where roads cannot absorb traffic from a large event, and provides a good example of how the disaster dictates the actions and not just plans.

Local Assistance Centers

The County has successfully established local assistance centers in 2008 and 2017 in response to multiple wildfires. The Camp Fire was so large that FEMA offered to stand up a disaster response center and Butte County participated with local resources.

Lessons Learned and Progress Achieved Over the Years

Based on lessons learned over the years the County has either implemented, or is in the process of implementing, a number of measures that improve the County's capabilities and preparedness for future disasters and emergencies. Provided below are many of those lessons learned and process improvements, though they may not currently be documented in formal plans.

This concludes the County's description of the many lessons learned and progress achieved as a result of dealing with multiple disasters. It is by no means an exhaustive list, but it demonstrates our ongoing effort to continually improve our capabilities and enhance future responses.

California State Auditor's Comments on the
Response From Butte County

To provide clarity and perspective, we are commenting on Butte's response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response.

Butte's implication that FEMA's best practices are of limited value for preparing for large-scale, catastrophic wildfires or that they are less applicable to jurisdictions with limited resources, is inaccurate and misleading. As we state in Chapter 1, FEMA has published guidance it describes as the foundation for emergency planning in the United States and that includes fundamentals of planning and developing emergency plans. Included in 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, including people with access and functional needs. FEMA designed these best practices to be applicable to all‑hazards, including catastrophic incidents like wildfires, and directs local jurisdictions to tailor their plans to their own communities and needs. Therefore, we did not measure Butte against any best practices that were inappropriate or inapplicable to the emergency situations it has already faced or could potentially face in the future.

Butte claims to be implementing many of the best practices we describe in our report. As we note in Figure 4, Butte has not implemented key best practices, including having up‑to‑date plans and conducting demographic assessments to determine its community's needs. Until it does so, Butte is not as prepared as it could be to protect and assist people with access and functional needs during natural disasters. We look forward to reviewing documentation of Butte's progress in implementing these best practices as it provides updates on its progress during our post‑audit follow-up.

Our report provides appropriate context and sufficient evidence to support our report's conclusions. The information that Butte provides in its response does not alter those conclusions.

We note the unprecedented size and scope of the Camp Fire in several places in our report, the first of which occurs in the Introduction. We also acknowledge in several places that is impossible to determine whether any additional planning efforts by Butte would have changed the outcomes of the Camp Fire. Regardless, as we note in Chapter 1, FEMA guidance states that inadequate plans and insufficient planning are proven contributors to failure. As we conclude in Chapter 1, Butte's planning deficiencies likely hindered its response to the Camp Fire.

Butte misstates and mischaracterizes our report's conclusions regarding the effects of its planning deficiencies. We explain earlier that because Butte did not fully implement important best practices for planning for natural disasters, its residents may be at greater risk of harm. These practices include having up-to‑date plans for critical emergency functions and prearranging vital resources. Butte acknowledged some of these gaps in its planning during our audit and does so again in its response. It is because Butte has not adhered to these practices—and not because of a lack of documentation—that Butte is not aligned with the foundational planning practices encouraged by FEMA and the result is that its residents may be at greater risk of harm than they would be if it had adhered to these practices.

In no part of our report do we state or suggest that emergency planning is more important than emergency response. Butte ignores the importance that both FEMA and Cal OES place on emergency planning and the connection between planning and response. As we note in Chapter 1, FEMA states that inadequate plans and insufficient planning are proven contributors to failure. Our report makes it clear that deficiencies in Butte's emergency planning caused problems during the Camp Fire, and therefore continue to threaten the effectiveness of Butte's disaster response efforts.

We accommodated every request that Butte made for additional time. In fact, at Butte's request we significantly rearranged our schedule for completing audit work, and delayed our first visit to Butte by seven weeks. Further, well in advance of its formal response period, we were clear in our communication with Butte about the conclusions we planned to report. We had several conversations with Butte about the audit's conclusions and a formal meeting at which it had the opportunity to read a draft of the report. We provided Butte the same amount of time we provide to all audited entities to respond to the final draft audit report and Butte never communicated a need for additional time to provide its response. We acknowledge that Butte is still recovering from the Camp Fire, but the suggestion that we were inflexible with the timing of our review is false.

In making this statement, Butte either misunderstands or disregards the scope of the audit that the Joint Legislative Audit Committee (Committee) requested we perform. As we describe in Appendix B, the Committee asked that we evaluate the counties' processes for ensuring that individuals with access and functional needs are accounted and cared for before, during, and after a natural disaster, in part by reviewing the extent that the counties' emergency plans incorporate best practices. As we describe throughout the report, Butte did not implement key emergency planning best practices before the Camp Fire and has not done so since. We are required by law to follow generally accepted government auditing standards, and those standards require that we examine the effects of the problems we identify in our audits. The effects of deficient emergency planning would manifest themselves most clearly in a county's response to a natural disaster. Therefore, we reviewed the extent that Butte's planning deficiencies caused problems during the Camp Fire. For instance, we describe how Butte's inadequate planning led to its inadequate alert and warning during the evacuations, which we describe in Chapter 1. We based these conclusions not on limited information as Butte asserts, but rather on sufficient and appropriate evidence, including documentation and interviews with staff in Butte who are directly responsible for emergency planning and who were involved in the response to the Camp Fire.

Consistent with its statements to us during our audit, Butte expresses an unnecessarily narrow belief that its agreements for disaster response resources must be limited to the resources available locally. As we describe earlier, the state emergency plan says that public-private partnership agreements can provide for quick access to emergency supplies and essential services. However, as we also note on that page, Butte had not established agreements for transportation resources to assist during evacuations. Additionally, although accessible showers are an important resource for people with disabilities in emergency shelters, Butte has not prearranged for this resource, as we state earlier, and struggled to obtain showers during the Camp Fire. Butte makes a general assertion that certain resources are not available in the county. If true, this assertion would make it even more important for Butte to prearrange agreements to obtain those resources, regardless of whether it would need to do so with vendors from outside of its immediate area. Finally, Butte's suggestion that it cannot take proactive steps to correct a shortfall of shelter supplies stands in contrast to Sonoma's approach. We note earlier that Sonoma has taken steps to directly purchase shelter supplies, including accessible showers.

We are glad that Butte indicates its willingness to use a variety of available data to assess the needs in its community. However, Butte's response suggests that this would merely continue an existing practice. As we note in Chapter 1, Butte has not conducted adequate assessments of its community to identify those with access and functional needs, or used existing county data in the development of its emergency plans. FEMA warns that failing to do so may lead to false planning assumptions, ineffective courses of action, and inaccurate resource calculations.

As we note in Chapter 1, Butte provided this plan after we sent the draft report to Butte for its final comment, and we will review the extent to which the plan incorporates best practices and addresses access and functional needs as part of our post-audit follow‑up process.

Because Butte included this statement in its discussion of changes it intends to make to its evacuation planning, we believe that Butte is referring to its outdated evacuation plan, not its all-hazard mitigation plan.

Butte's statements suggest that it does not understand the best practices related to tailoring its emergency plans to its own community. It describes its use of various sources of information available regarding people with potential access and functional needs in its community. Although in its response it calls its use of this information pre-planning, Butte is actually referring to the incident response planning that a local jurisdiction does once it is actively responding to an emergency situation. This is wholly different than the best practice of assessing community needs in advance of a disaster.

As we indicate in Chapter 1, and as we discussed with staff at Butte several times during our audit, FEMA recommends that, prior to a disaster, local jurisdictions conduct demographic assessments of their communities to understand the needs that the people in their communities will have during an emergency, which is critical to identifying people with access and functional needs. Local jurisdictions can then use this information in the development of their emergency plans to help ensure that they can meet those needs. As it relates to evacuation planning, we explain earlier that Butte had not conducted such assessments or used demographic information in its planning to identify the number of people who may need assistance evacuating, which would allow it to better estimate the evacuation resources it should have available.

As we further explain, by not making use of existing county data when planning for emergencies, Butte is missing an opportunity to expedite evacuation assistance when natural disasters occur. Until Butte assesses the needs of its community and uses the information it obtains in the development of its emergency plans, it risks encountering the problems that FEMA warns can happen when jurisdictions do not base their emergency planning on its community's demographics—false planning assumptions, ineffective courses of action, and inaccurate resource calculations.

We are glad that Butte intends to implement our recommendation that it follow best practices related to developing agreements with transportation providers. As part of implementing this best practice, it will be important that Butte assess how many people within its jurisdiction may need evacuation assistance, as well as the transportation resources that agreements with transportation providers will make available so that it can determine whether those resources will be sufficient.

Butte's inaccurately portrays its sheltering plan and assessments of shelter facilities. As we discuss in Chapter 1, Butte's sheltering plan is significantly outdated. Additionally, during our audit Butte provided a list of 100 shelter sites but it had only completed assessments for three sites to determine whether they were accessible to people with disabilities, and the assessments were completed in 2007. Butte's director of employment and social services stated that Butte intends to establish agreements with more shelter locations in the next year, and will include completed access and functional needs assessments for those locations. Until it does so, Butte will remain underprepared to address access and functional needs in its emergency shelters.

To the extent that Butte has historical data from multiple disasters regarding how many people may seek shelter, including how many may have access and functional needs, it should incorporate that into its planning as contemplated by FEMA best practices. As we describe in Chapter 1, those best practices indicate that local jurisdictions should conduct demographic assessments to know the demographic profile of their communities and understand the type of assistance that their various populations may require during a disaster. However, as we further note, Butte had not performed such assessments. Butte further indicates in its response that it intends to continue its use of a planning tool to calculate shelter estimations and resources. As we note in a later section, FEMA states that a community's demographics can have a profound effect on shelter operations. Therefore, Butte should not rely on generalized estimates when planning for resources to support the people in its community who seek shelter.

Butte's stated plan will not address the problem it has with outdated emergency plans or our recommendation. As noted in several places in our report, Butte has not updated its emergency plans since 2011. The time since its last update significantly exceeds FEMA's recommendation to update emergency plans every two years and the five-year interval within which the State is required to update its emergency plan. As we note in Chapter 1, FEMA states that outdated plans can cause setbacks for local jurisdictions during an emergency because of old information, ineffective procedures, incorrect role assignments, and outdated laws. Because of the importance of keeping these plans up-to-date and because we recognize that many interests compete for local resources, we recommend that Butte place a priority on updating its plans regularly by adopting a requirement to do so in a county ordinance. Further, Butte demonstrated that it has the ability to update its plans while also balancing other important disaster recovery activities when in October 2019, while recovering from the Camp Fire, it updated its alert and warning plan.

Butte claims to have taken various preparedness actions for which it states that it has no documentation. None of these actions would change the veracity of our findings or the conclusions that we have made, including that, Butte is not as prepared as it could be to protect its residents during future natural disasters, including people with access and functional needs, because it has not followed key practices for emergency planning.

Our conclusion that Butte has not adequately followed best practices for emergency planning is not based on assumptions, nor is it based solely on the fact that Butte does not have an updated emergency operations plan, or on Butte's lack of documentation of its response procedures and practices. Our conclusion is based on substantial evidence that Butte has not implemented best practices that FEMA identifies as important for effectively responding to disasters. Although as we discuss earlier that it is problematic that Butte has not updated its emergency plans for many years, it is also problematic that Butte has not adequately assessed the needs of its community to inform its emergency planning, has not prearranged key resources to protect and support people with access and functional needs during emergencies, and has not adequately involved people with access and functional needs in emergency planning.

Butte's response lists several stakeholder entities and groups with which it states it collaborated during emergency planning. However, as we note earlier, Butte could not provide evidence of its involvement of representatives of people with access and functional needs, including community organizations, in emergency planning. We further note that Butte's description for how it involved those representatives falls short of best practices for involving people with access and functional needs in planning. Until it adequately involves them in emergency planning, Butte will continue to miss an opportunity to learn what individuals in its community need during natural disasters and how it can prepare to meet those needs.

Butte describes steps that it took in the development of its 2011 evacuation plan. However, as we note in Chapter 1, that plan is significantly outdated, does not align 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. Further, Butte asserts that part of its planning effort included collaboration with other agencies to develop evacuation zones and routes. However, those zones and routes are not mentioned in Butte's evacuation plan, which may represent yet another shortcoming of Butte's outdated plan.

Butte misrepresents our conclusions. Our report does not say that resources are not available. Rather, we conclude that Butte has not adequately implemented best practices for ensuring the availability of critical resources during natural disasters, including supplies that are important for supporting people with access and functional needs. As we describe earlier, 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 with suppliers. The state plan says that public-private partnership agreements can provide for quick access to emergency supplies and essential services. However, as we note in that same section, although Butte has prearranged for many shelter supplies, it has not prearranged transportation agreements for providing evacuation assistance. Similarly, as we describe in a later section, it has not prearranged to obtain accessible showers. Both of those resources are critical to support people with access and functional needs during disasters, and we describe, how Butte struggled to obtain those resources during the Camp Fire.

Butte claims to have prearrangements for buses and paratransit buses for evacuations; however, it does not. As Butte acknowledges in its response, and in our report, Butte lacks agreements for transportation resources for providing evacuation assistance.

Our report does not require clarification. In its full context it is clear in our report that Butte does not have prearranged agreements to obtain transportation resources. Further, we state clearly in Chapter 1 that Butte has not conducted assessments of its community to determine the number of people who may need evacuation assistance. As a result, Butte cannot know whether the transportation resources it states it knows about will be sufficient to provide evacuation assistance to the people in its community who will need it during a natural disaster.

Contrary to Butte's statement, our report makes no "assertion" about Butte's preparation to alert and warn its residents in advance of the Camp Fire. Instead we based our conclusion that Butte was not as prepared as it could have been on the documentation we reviewed—including Butte's outdated alert and warning plan, which makes no mention of a major federal alerting system—and the confirmed statements from responsible staff at Butte—who agreed that the county had not developed pre-scripted message templates and that doing so would have helped Butte better adhere to best practices during its response to the Camp Fire. Additionally, contrary to Butte's stated belief, our conclusion does take into account no-notice events. The best practices we describe, including developing message templates in advance of a natural disaster, are designed to enhance a local jurisdiction's ability to quickly send alert and warning messages during no-notice events. Further, as we note earlier, advance planning improves a local jurisdiction's ability to effectively manage response operations in the face of the complexity and uncertainty inherent in natural disasters. As we state earlier, by not implementing these best practices, Butte impaired its ability to effectively warn its residents of the impending danger from the Camp Fire.

Butte's statement is inaccurate. In Chapter 1 we note that Butte asserted that it used multiple methods for alerting and warning people during the Camp Fire, and we acknowledge that Butte used methods such as email and social media. However, we also note that none of those methods have the ability to reach as many people as quickly as WEA messages, which are designed to reach all cell phones in an evacuation area.

Butte did not send WEA messages during the Camp Fire, which we note in Chapter 1. As we describe earlier, Butte asserted that it attempted to send a WEA message, but the message failed to send through its software program. However, as we further state, Butte did not follow FEMA guidance to test its software to ensure that it was functional before a natural disaster. The WEA messages that Butte refers to that it subsequently sent were alert and warning messages to warn residents of flooding that occurred after the Camp Fire.

Butte's incorrectly asserts that our report does not acknowledge that it initiated messages to landline phones. We state that Butte issued emergency messages through its local emergency alert and warning systems, which uses contact information, such as cell phone numbers, that residents provide, as well as landline contact information that the counties purchase from service providers. We further note that only using this system, and not issuing a WEA message, was inherently problematic given the public's declining use of landlines and the small percentage of people who sign up for cell phone alerts.

We do not criticize Butte for things that occurred during the Camp Fire that were outside of its control. In Chapter 1 we acknowledge that, because of infrastructure challenges and the limitations of any given alerting method, it is unlikely that Butte could have alerted every single person within the evacuation zones. However, Butte's response directs focus away from problems that it could have prevented through better preparation. As we describe in an earlier section, Butte did not maintain an up‑to‑date alert and warning plan, did not follow advice from FEMA to test its WEA message capabilities in advance of a disaster, had not pre-scripted messages to ensure they contained the advised information, and had not planned to issue messages in languages other than English.

As a result of these planning deficiencies, Butte was less prepared during the Camp Fire to issue WEA messages, issue messages that contained all advised information, and issue messages in languages other than English. Finally, we disagree with Butte's assertion that best practices would not strengthen response to catastrophic wildfires. The preparation steps we describe in our report would better prepare a county for any disaster, regardless of size and scope. Therefore, it is likely that they would have yielded additional benefit during the Camp Fire. Also, Butte's own adoption, following the Camp Fire, of an updated alert and warning plan and pre‑scripted message templates in English and other languages seems to indicate it agrees these are preparedness steps that will enhance its disaster response.

The challenges that Butte describes related to developing alert and warning messages that are limited to 90 characters underscore the importance of developing alert and warning message templates in advance of a disaster. As we indicate in Chapter 1, Butte had not done so before the Camp Fire. Butte appears to recognize the value of preplanning to address the character limit because the message templates that Butte developed during our audit in English, Spanish, and Hmong, contain templates for 90 character messages.

Butte indicates that it did not send alert and warning messages in languages other than English because it did not have translation capabilities immediately available during the Camp Fire. However, as we discuss in Chapter 1, Butte had not followed best practices stating that local jurisdictions should develop pre‑translated message templates. If it had completed this planning step in advance of the Camp Fire, Butte would have been better positioned to send messages in languages other than English.

Butte's suggestion that including the source of its alert and warning messages was not necessary during the Camp Fire is contrary to best practices, which we describe earlier and which state that the response that individuals have to an emergency alert depends in part on the level of trust that they have in the source. Nevertheless, during our audit, Butte developed alert and warning message templates that contain the source of the messages, which indicates that Butte believes there is value to including that information in its emergency communications.

Our report does not state that the county's Special Needs Awareness Program (SNAP) registry only contains IHSS clients. We state that Butte's in-home support services (IHSS) agency maintains a list of people who receive IHSS and will require assistance during an evacuation, and that 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. It enables residents to do so through the county's SNAP program. We further note in that same section that, contrary to best practices, Butte did not use this information in the development of its emergency plans.

Butte indicates that it has taken the actions it lists here, though it may lack documentation to support them. Regardless, none of the claims that Butte makes in this list change any of the conclusions that we make in our report. Additionally, many of the actions that Butte describes are actions that it claims to have taken following the Camp Fire or will take in the future. We look forward to reviewing how Butte incorporates these actions, and the best practices from FEMA and Cal OES, into its updated plans during our post-audit follow-up process.

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Sonoma County

November 12, 2019

Ms. Elaine M. Howle, CPA
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Re: 2019-103 County Emergency Plans-Evacuation of Residents with Access and Functional Needs Audit

Dear Ms. Howle,

Please find enclosed the County of Sonoma's response to the above referenced audit. As you are no doubt aware, Sonoma County has been heavily impacted by various natural disasters in recent years. As such, the County very much appreciates the interest of the Joint Legislative Audit Committee in requesting this audit, and the work performed by the audit team regarding this very important subject matter. The County of Sonoma looks forward to working collaboratively with the California State Legislature, the Governor's Office of Emergency Services, and our residents and local stakeholders to strengthen the emergency planning, preparedness and response throughout the State of California for all its residents and visitors.


Sheryl Bratton,
County Administrator
County of Sonoma

County of Sonoma Response to 2019-103 County Emergency Plans-Evacuation of Residents with Access and Functional Needs Audit

The County of Sonoma appreciates the opportunity to respond to the 2019-103 County Emergency Plans-Evacuation of Residents with Access and Functional Needs Audit, performed by the California State Auditor's Office, at the request of the California Joint Legislative Audit Committee. Meeting the disaster response needs of the most vulnerable in our community must be one of the highest priorities of state and local emergency service planners and this audit shines welcome light on the issue. In particular, the report finds that there are not any state regulatory guidelines or statutes to guide a uniform approach. Further, there are no State resources dedicated to providing effective leadership serving this growing population of Californian's with access or other functional needs (AFN) barriers to effective disaster response. The County of Sonoma agrees that more uniform guidance and support should be provided to county agencies who are the primary jurisdictions responsible for emergency planning, preparedness and response.

In the absence of specific legal requirements, the audit researched relevant best practices as benchmarks that might be applicable to specific situations depending on the factual circumstances. We agree that if the best practices are worthy of statewide applications, it would be useful for the State to provide uniform guidance. In Sonoma County, important lessons were learned from responding to the 2017 Sonoma Complex firestorm that erupted late at night on October 8, 2017, and traveled 11 miles in 4 hours, quickly consuming over 5,000 homes and covering more than 170 square miles. Many of these lessons and best practices were applied in the recent Kincade Fire, where despite being hampered by successive PG&E power shutoffs that degraded communication capacity, the County successfully implemented the biggest evacuation and repopulation in Northern California history with a particular focus on AFN populations.

The Kincade Fire, which burned 77,758 acres, which was larger than any single fire during the Sonoma Complex Fires, was fully contained on November 6, 2019. The Kincade Fire emergency response orchestrated the evacuation and repopulation of almost 200,000 residents. This successful evacuation was responsible, in part, for no loss of life during the disaster.

Sonoma County is proud of its efforts to meet the needs of our AFN population during the recent disaster, which showed implementation of applicable best practices and lessons learned. As part of that effort, the County also sheltered approximately 3,400 residents, with a high percentage having access or functional needs. Persons coming to the shelter were screened by the Human Services Department Functional Assessment Service Teams (FAST), who assessed individuals to ensure their special needs were addressed. In addition, the County assisted with the evacuations of two hospitals and at least four residential care facilities. Many of these elderly care facility residents were accommodated at the County evacuation shelters.

In addition, both before and during the Kincade Fire, Sonoma County was subject to repeat and extended PG&E power shutoff events involving over 250,000 residents, in which special outreach was conducted to AFN populations. The County has 6,232 In-Home Supportive Service (IHSS) clients who represent many of the most vulnerable members of the community. Prior to the power shutoffs and fire, the County Human Services Department worked with the IHSS clients and caretakers to develop emergency response individualized preparedness plans. During the emergencies, social workers made individual contacts to 2,748 clients identified as Critical, Urgent and Moderate need. These contacts helped ensure that clients in the evacuation area had means to leave and that individuals had plans in place to cope with the power shutoffs. In cases where the clients were in distress, social workers were dispatched to the home to provide aid. In addition, outreach was also made to 463 PG&E medical baseline customers who the utility was unable to reach to provide similar support as well as to federal Department of Health and Human Services emPower clients.

Examples of actions taken as a result of this outreach included a person from the PG&E Medical Baseline list, who the utility did not contact, who had energy dependence regarding oxygen needs and was in distress. County social workers contacted a local medical supplier for the individual and arranged to have replacement tanks delivered. A second example was a senior citizen who was on both the medical baseline and IHSS list and was a breast cancer survivor who used a nebulizer and relied on a CPAP machine at night. She reported not having enough food and couldn't get her car out of the garage due to having an electric garage opener. The Human Services Department Functional Assessment Service Team (FAST) member coordinated with the Disability Services and Legal Center (DSLC) to get the individual a backup battery, deliver food and water, and unlatch their garage door in the event they needed to evacuate their home.

The Kincade emergency response efforts have received praise by both Cal Fire and Cal OES. These vastly different outcomes in the two firestorm events are not only attributable to the brave and heroic firefighters who battled the fire but also to the efforts by Sonoma County and its residents to be better prepared to respond to a natural disaster. We know each event is different and brings its own lessons and best practices that can be incorporated into future planning.

The successful response to the Kincade Fire was the result of intensive efforts to improve readiness. Before October 2017, the County of Sonoma was prepared to respond to natural disasters, likely better than most. Since October 2017, the most significant thing learned from the Sonoma Complex Fires is that we, local governments and residents, can never be prepared enough. Based on the experiences of the Sonoma Complex Fires and the 2019 Winter Storms and Flooding, County staff and allied stakeholders have worked tirelessly to increase the capacity of our residents and communities to respond to future fires and other disasters. In the first year following the fires, most County efforts focused on short-term recovery activities and assessing the response. The second year was characterized by a shift to long-term recovery activities as well as implementing changes in order to be better prepared for future disasters.

An important product of these efforts was that the Sonoma County Board of Supervisors adopted Sonoma County Recovery and Resilience Framework, as well as a specific program to test and improve the County's Alert and Warning program and Emergency Operations Center (EOC) functions. For example, in the recent Kincade Fire, the successful evacuation of over 190,000 people was accomplished by coordinated alert and warning messages sent in both English and Spanish through the sending of 15 Wireless Emergency Alerts, 26 SoCo Alerts, the first ever use of the NOAA Weather radio system west of the Rocky Mountains, Nixle messages, and the use of Hi/Lo warning sirens, all of which directed recipients to the real time posting of evacuation zones on the County's Emergency website, which received over 2 million views. The response to the Kincade Fire was not reviewed in the audit.

While identifying and overcoming limitations in alert and warning systems has been a major area of focus, other important improvements have been implemented since the October 2017 Sonoma Complex Fires to its emergency planning, preparedness and response efforts. These actions include:

The list above is a sample of the accomplishments the County of Sonoma has achieved in improving its emergency response capabilities in the two years since the Sonoma Complex Fires. During the recent October 2019 Kincade Wildfire – the largest in the County's history – and the concurrent PG&E power shutoff to 260,000 residents, the County demonstrated significant capabilities including:

As stated above, the County recognizes that while much has been accomplished, more must be done. We look forward to reviewing the full audit report, including recommendations for guidance, assistance, establishment of state standards, and the provision of funding and other resources to assist California counties with providing the best emergency response services available. The County of Sonoma stands ready to be partners with the Legislature, Cal OES, Cal Fire, other counties and local governments, stakeholders, and most importantly, the residents of Sonoma County, to improve local emergency planning, preparedness and response.

Sonoma County's Response to the Audit Report's Recommendations

Recommendation No. 1:

To best prepare and care for people with access and functional needs, Sonoma should revise its emergency plans by following the best practices identified in the report. Sonoma should begin implementing these practices as soon as possible. By no later than March 2020, Sonoma should develop a schedule for completing updates to its emergency plans.

County Response to Recommendation No. 1:

Sonoma County will implement the recommendation to update emergency plans by March 2020 and looks forward to including additional statewide adopted standards in serving AFN and other vulnerable populations.

Recommendation No. 2:

To ensure that it maintains updated emergency plans that are consistent with current best practices, Sonoma should adopt ordinances establishing requirements for the frequency with which it must update its emergency plans and should set that frequency at no greater than five (5) years.

County Response to Recommendation No. 2:

This recommendation will be implemented by March 2020.

Recommendation No. 3:

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

County Response to Recommendation No. 3:

The County's response to the Kincade Fire demonstrates that much of the substance of this recommendation has already been implemented. The County of Sonoma does intend to refine its policies to include adoption of applicable guidance and FEMA, Cal OES and other relevant best practices. The County looks forward to incorporating statewide standards into its updated emergency plans and working with the State as a partner in developing these important guidelines.

The County of Sonoma will adopt a policy that the Director of Emergency Management report publicly to the Board of Supervisors during emergency planning about the steps taken to address access and functional needs.

The County of Sonoma does intend to continue to implement its policy that the County will consult periodically with a committee of community groups that represent people with a variety of access and functional needs and to request that representatives of the community groups committee present to the Board of Supervisors their review of the adequacy of the emergency plans.

The County of Sonoma does not agree with the recommended process for implementing the recommendations. Best practices, by definition, are reliant upon the specific facts and circumstances of a situation and formalizing these steps into local law does not create the type of flexibility needed in responding or planning for a disaster response. Instead, the Board of Supervisors will adopt policies that implement the above which will provide a better mechanism to improve and expand upon them as state standards and best practices change, rather than more formalized and time intensive amendments to local ordinances.

The County intends to adopt the policies stated above by March 2020.


To provide clarity and perspective, we are commenting on Sonoma's response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response.

Sonoma's suggestion that the best practices we applied as criteria in our review might only be applicable to specific emergency situations is inaccurate. As we state in Chapter 1, FEMA and other emergency management authorities have published best practices that they advise emergency management agencies to follow so that they develop the best possible emergency plans. Included in these best practices are having specific plans for critical emergency functions and ensuring that those plans address the needs of the whole community, including people with access and functional needs. FEMA and the other organizations designed these best practices to be applicable to all hazards, including catastrophic incidents like wildfires, and directs local jurisdictions to tailor their plans to their own communities and needs. Therefore, we did not measure Sonoma against any best practices that were inappropriate or inapplicable to the emergency situations it has already faced or could potentially face in the future.

Sonoma describes its response to the Kincade Fire, which we did not review because it occurred while we were finalizing our audit report for publication. Accordingly, we have no assessment on the degree to which Sonoma's response to that disaster was adequate or influenced by planning steps it had taken in advance of the fire.

Sonoma appears to point to its response to the Kincade Fire as evidence that it has addressed best practices for planning and preparedness. As we state earlier, FEMA guidance directs local jurisdictions to develop plans for alert and warning, evacuation, and sheltering, all of which should contain strategies for how the jurisdiction will assist people with access and functional needs. However, we found that Sonoma does not have these plans. Therefore, Sonoma's asserted success during the Kincade Fire does not modify our conclusion that Sonoma has not followed best practices and done all it can to prepare to support people with access and functional needs. Additionally, as Sonoma indicates in its response, it should ensure that it develops plans informed by lessons learned from the disasters it has experienced to enable it to be better prepared to deal with future disasters.

Despite its suggestion to the contrary, Sonoma was not adequately prepared to respond to natural disasters before the Sonoma Complex Fires in October 2017. Sonoma's response is contradictory to the after-action report it published after the Sonoma Complex Fires, which we describe in Chapter 1. The after-action report notes 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 similarly sized disasters. Sonoma's report concluded that these past experiences were insufficient in preparing the county for the 2017 fires, which the report states was the most significant disaster in living memory in Sonoma. Further, Sonoma's response lists several improvements to its emergency planning and response capabilities that the county undertook after the Sonoma Complex Fires, thereby acknowledging improvements were needed. We look forward to reviewing its progress in addressing emergency planning best practices during our post-audit follow-up process.

Sonoma lists actions it has taken to improve its alert and warning program since the Sonoma Complex Fires. However, even though Sonoma developed a draft alert and warning plan in August 2018, it still has not adopted a finalized alert and warning plan. Further, as we describe earlier, best practices from FEMA and Cal OES suggest that emergency management agencies should involve individuals with a variety of access and functional needs and local community organizations in all aspects of the emergency planning process because those individuals understand what they will need during disasters. However, as we indicate earlier, Sonoma has not done so when developing its draft alert and warning plan. In its current form, Sonoma's draft alert and warning does not include strategies for how it will reach its residents who are deaf or hard of hearing during an emergency. Therefore, until it includes individuals with access and functional needs in its planning process, Sonoma risks overlooking the planning gaps that exist related to warning its whole community.

We acknowledge that Sonoma is in the process of developing additional evacuation plans. However, the FEMA guidance we describe earlier states that counties should develop all-hazard evacuation plans that broadly apply to a wide range of emergencies, including different types of natural disasters, and should include provisions for evacuating individuals with access and functional needs. As we discuss earlier, Sonoma did not have an all-hazard evacuation plan and its hazard-specific plans did not contain strategies for how the county planned to address residents' access and functional needs during evacuations. To better ensure that it has considered evacuation needs for the whole community and captured the strategies to accommodate these needs in an all-hazard evacuation plan, Sonoma will need to include representatives of people with access and functional needs in its planning efforts.

Consistent with the confidentiality restrictions of an ongoing audit that state law mandates, we did not share our findings or conclusions about other entities we reviewed during the course of our audit with Sonoma. Therefore, Sonoma's response includes its assumptions about the results of the rest of our review. Contrary to Sonoma's assumption, our report does not contain a recommendation to fund counties so they can implement best practices from FEMA and Cal OES. Specific to Sonoma, there are two key reasons we do not make such a recommendation. First, as we describe in Chapter 1, the director of emergency management could not provide a formal estimate for how much it would cost the county to implement the best practices. Second, as we explain earlier, Sonoma developed and approved a recovery and resiliency framework, which includes actions that overlap with some of the best practices that we reviewed and describe in our report. That framework indicates Sonoma has already planned to incur many of the costs associated with emergency planning best practices, making a recommendation for State funding unnecessary.

Our recommendation that Sonoma adopt county ordinances requiring it to implement best practices when developing emergency plans does not create inflexibility, as Sonoma suggests. We did not recommend that Sonoma codify the specific best practice language we include in Figure 11. Instead, we recommend that Sonoma adopt a broad requirement that it follow best practices when planning for emergencies. We specifically recommended Sonoma use a local ordinance because of the importance of these practices and the results of our review which show that Sonoma has not historically followed these practices. Although we acknowledge that Sonoma plans to commit to these actions through a policy, county ordinances are a stronger and more appropriate commitment to the best possible emergency planning because it makes that commitment a legal requirement.

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Ventura County

October 30, 2019

Ms. Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Dear Ms. Howle,

The Ventura County Sheriff's Office of Emergency Services, Ventura County Fire Protection District, Human Services Agency, Public Health Department, Emergency Medical Services Agency and County Executive Office appreciate the State Auditor's review of the County's emergency plans related to the safe and efficient evacuation of residents with disability, access and functional needs (DAFN). However, we feel that the report does not adequately reflect many of the proactive actions and steps we have taken to prepare and respond to unprecedented and significant disasters, as well as the overwhelmingly successful outcomes achieved. Specifically, during the Thomas, Hill, and Woolsey Fires, the safe and successful evacuation of nearly 200,000 individuals, sheltering of hundreds from our communities, and, no fatalities attributable to potential access and functional need planning gaps, as noted on page 17 of the draft audit report.

Still, we appreciate the work performed by the California State Auditor's Office in preparing this report and welcome the opportunity to further enhance our planning and response efforts to best meet the needs of all members in the communities we serve. We acknowledge that the County should involve the DAFN population more in our emergency planning efforts, and, though we believe a nimble, flexible evacuation response has proven more effective, the County should have a written plan that describes this process and, as was previously acknowledged and addressed during the Thomas Fire, our emergency website in Spanish should have been executed with live translation (instead of Google Translate) and VC Alerts should have been sent in Spanish from the beginning.

The State Auditor's Office Report (Emergency Planning 2019-103) underscores the importance of planning and preparing to meet the needs of some of the most vulnerable in our communities and we share in this understanding, as well as the goal of improving efforts in this area. In fact, the culture of continuous process and service improvement that is a core value for us in Ventura County has resulted in some of the best possible outcomes in responding to the recent disasters we have faced. The Thomas Fire in December 2017, which was the largest wildfire in Ventura County and California history at the time, resulted in the evacuation of nearly 100,000 members of our communities with no loss of life associated with disability, access and functional needs planning efforts.

In the following response, we first provide some background with respect to the disasters analyzed as part of the audit, as well as the results of our planning and response efforts for the report. Additionally, we share our conclusions with recommendations contained in the report and highlight efforts already underway or completed to improve upon the DAFN components of our planning and response efforts.

The Thomas Fire, Borderline, Hill and Woolsey Disasters

The Thomas Fire occurred on December 4, 2017. This fire was not a normal fire, nor was it a normal disaster; instead it was unlike anything anyone had ever seen in the history of the County. As a result of seven years of drought, vegetation in the hills surrounding Ventura County was exceptionally dry and had the lowest live fuel moistures that could be recalled. The winds that materialized were beyond significant and the relative humidity was in the single digits.

A few days prior to the fire, a strong Santa Ana weather pattern was beginning to form, and County emergency service providers were paying close attention. On December 2, 2017, staffing augmentations were identified for December 3-5 in anticipation of the increased risk. Ventura County Fire Department staffing was augmented, or as Cal OES now refers to it, prepositioned, on December 3 at a moderate level, then on December 4 at a very high level. (The prepositioned staffing on December 4 before the Thomas Fire started was 87% higher than regular daily staffing.) Not only were more emergency apparatus staffed, our preparation also included additional dispatchers for the communications center. A fire department conference call was held on December 3 to coordinate for the red flag wind event over the next 24 hours. On December 4 the Ventura County Sheriff's Office of Emergency Services (OES) coordinated an Operational Area conference call to discuss the elevated fire weather and countywide preparedness.

When the Thomas Fire started the evening of December 4, the County was well prepared. The speed at which the fire moved and progressed had never been seen before. Even if the fire department had engines in close proximity to the ignition point of the fire, it is highly unlikely that the fire could have been contained, as its rapid spread was almost instantaneous. Emergency response to the fire was significant and robust. Within the first few hours, fire ground commanders had placed orders for an additional 70 strike teams (350 engines staffed with over 1,500 firefighters). The County quickly recognized that the fire was moving so rapidly that there was not time to wait for the statewide ordering system to fill orders for fire engines. Accordingly, the fire chief and the incident commander both made phone calls to fire chiefs from neighboring agencies outside of the County to send their engines, outside of the normal ordering process. After many years of dealing with the failings of the statewide ordering system, which would theoretically be considered a best practice ordering system, the fire chief gave direction to bypass the system so that Ventura County could have resources on scene more quickly. Thanks to quick decision-making and response from our neighbors, this effort was highly effective and has been repeated many times since.

Additionally, as a result of highly competent fire ground commanders anticipating the fire behavior and its likely path, proper evacuation decisions were made. There was a highly coordinated and seamless evacuation effort between Ventura County Fire Department, Ventura County Sheriff and Ventura County OES all working together at the command post. This expedient, purposeful and well-coordinated evacuation effort resulted in an outcome of zero fatalities that could be attributed to evacuation planning or a lack thereof. It is difficult to develop an evacuation plan that addresses all evacuation scenarios; however, the agile process that the County followed allowed us to successfully navigate this incredibly dynamic and fast-moving fire. In our collective memories, we cannot recall any time when fire engines had to focus their efforts on actively evacuating civilians instead of protecting homes from the fire. The primary point being, the Thomas Fire was not an ordinary fire that, at the time, could have been predicted, anticipated or prepared for in the way that hindsight prepares us for responding to an emergent incident after the fact.

Ventura County's proactive approach to these emergency incidents also resulted in a request to FEMA in the form of a Fire Management Assistance Grant (FMAG) being applied for within the first few hours of the fire. This request was coordinated with the Governor's Office of Emergency Services.

As a result of the successes with the Thomas Fire, the Ventura County Fire Chief was invited to Sacramento to testify on two occasions regarding the County's best practices. We highlighted the prepositioning of resources in advance of the start of the fire and the fact that it saved lives. We also highlighted the fact that, by going around the normal ordering process, we were able to get resources into the City of Ventura much more quickly and, as a result, saved homes and likely saved lives. At the time, this was not done in other fire responses throughout the state.

The Chief's testimony and significant efforts by the California fire service led to support from the Legislature for a one-time expenditure of $25 million to upgrade technology infrastructure and revamp the statewide ordering system. Additionally, the Legislature allocated one-time funds in the amount of $25 million from the Greenhouse Gas Reduction Fund (GGRF) so that all local government agencies could preposition resources as Ventura County did. Governor Newsom recognized the value of prepositioning resources and has now made the $25 million prepositioning funds a permanent and ongoing part of the state budget. This new program is administered by Cal OES.

Within just eleven short months, Ventura County faced three new catastrophes that would further tested our emergency planning and response efforts and once again demonstrated the extraordinary preparedness of the County, our local government partners, community-based organizations and the remarkable members of the communities of Ventura County. On November 7, 2018, a mass shooter tragically took the lives of 12 individuals at the Borderline Bar and Grill in Thousand Oaks, California and injured nearly a dozen others. Among the victims were Ventura County Sheriff Sergeant Ron Helus who entered the facility to stop the attacker and was fatally wounded during his heroic response. Immediately upon the heels of this tragedy, in less than 24 hours, on November 8, a fast-moving wildfire started in Hill Canyon east of the City of Camarillo and was being driven to the west by the strong winds. The Hill Fire reached Highway 101 in less than 15 minutes, jumped the freeway and briefly threatened the community of Camarillo Springs before burning up and over Conejo Mountain and into the community of Newbury Park. It destroyed five structures there and was eventually contained at about 4,500 acres. But the Hill Fire was just the start.

About 20 minutes after the start of the Hill Fire, at 2:30 p.m., another fire was reported near Woolsey Canyon Road in Simi Valley. The fire quickly became a threat to life and property as it raced towards the City of Thousand Oaks. Evacuations were ordered in the community of Oak Park and, soon after, in Thousand Oaks, then all the way to the Los Angeles County line.

The fire jumped Highway 101, burning into Los Angeles County, triggering more evacuations as it moved toward the coast. Homes were threatened in the cities and communities of Westlake Village, Agoura Hills, Calabasas, Hidden Hills, Bell Canyon and Malibu, as well as homes in the canyons between Highway 101 and the Pacific Coast Highway. More than 90,000 people were under evacuation orders in Ventura County alone and tens of thousands of homes were threatened.

The President of the United States and the Governor of California eventually toured the fire area. Emergency declarations by both, a local emergency declaration by the Sheriff and a Public Health Emergency declaration allowed the recovery effort in Ventura County to begin almost immediately. Emergency resources continued to pour into Ventura and Los Angeles counties. The response included 688 fire engines, 41 aircraft (helicopter and fixed-wing), 82 hand crews and 24 bulldozers.

At the peak of the Woolsey Fire, more than 5,000 emergency personnel were assigned to the incident. The fire would consume 96,949 acres – 152 square miles - an area larger than the entire cities of Detroit or Philadelphia. It destroyed 1,643 structures (185 homes in Ventura County) and damaged another 364 (115 in Ventura County). Animal Services sheltered 356 animals including horses, dogs, cats, chickens, rabbits and even three alpacas. Almost 20,000 hotline calls were answered by the Office of Emergency Services. The OES also issued 40 VC Alerts in English and Spanish, three Wireless Emergency Alerts and three Emergency Alert System Messages in addition to door to door, social media, website, and broadcast alert messages.

Ventura County's emergency information website – – had more than two million unique page views during the fires. The site listed current evacuation orders, fire updates, and road and school closures all in both English and Spanish. At one point, both Highway 101 and the Pacific Coast Highway (Highway 1) were closed to civilian traffic.

Despite the unprecedented significance of the Thomas, Hill and Woolsey Fires, Ventura County successfully evacuated over 200,000 people, sheltered hundreds of displaced individuals and worked quickly to connect those impacted with key resources at local assistance centers. Across the Thomas, Hill and Woolsey Fires, there were four civilian casualties, none of which were directly related to emergency planning and response associated with individuals having disability, access and functional needs: two that occurred during debris removal and infrastructure repair activities in the weeks following the fires and two that occurred during private civilian evacuations.

Considering the magnitude and scale of these events, no significant findings related to the County's response or management of these extraordinary incidents have been identified, following expansive after-action review processes with the exception of language translation and other items noted in this response. Additionally, Ventura County is widely recognized as a County of "best practice" by its peers, having received accolades from response partners from across California for our response to the Thomas Fire.

Even with such demonstrated and proven success using current methodologies to respond and manage natural disasters, the County of Ventura takes pride in being a county of continuous improvement. Following any incident, there are always new lessons learned and opportunities to strengthen existing strategies. Ventura County is quick to recognize these lessons learned and continually strives to implement change for the betterment of the communities we serve. In the following segments, arranged in the order of the key areas of focus of the State Auditor's Report, we provide feedback concerning the recommendations contained in the report and highlight efforts already taken to improve upon the DAFN components of our planning and response efforts.

Emergency Plan Development

Audit Recommendation: Use a diverse planning team, including people with a variety of access and functional needs and community organizations that support them.

Ventura County has made a significant investment through the years establishing critical relationships with response partners, conducting pre-planning activities, testing pre-planning through exercises and educating the community on what to expect from first responders during an emergency. In the Fall of 2009, the County Board of Supervisors established the Ventura County Emergency Planning Council (EPC), whose purpose is to provide for the preparation and carrying out of plans for the protection of persons and property within the County. With this action, the Board also identified members of the EPC as representatives from the county, cities, business, military, infrastructure/lifelines, including representatives from health care, special districts, colleges/schools, local non-governmental organizations, volunteer organizations active in disasters, and other members-at-large. The EPC reviews and recommends emergency and mutual aid plans and agreements for adoption by the Board.

Prior to this audit report, Ventura County followed what we perceived to be CalOES best practice in the development of a Disability, Access and Functional Needs Plan that addressed preparedness, alert warning, transportation, evacuation and care and sheltering. The plan additionally identifies the primary County, non-profit, non-governmental partners, and for-profit entities that support the DAFN population, as well as the defined and documented role of the DAFN Coordinator embedded within the Ventura County Emergency Operations Center. During the Thomas Fire, the County took a prominent lead to be responsive to community needs. County teams and resources provided satellite outreach and education and attended and led community events and listening sessions to not only educate the community, but to best understand disability, access and functional needs across the impacted areas.

After the Thomas Fire, the County and the American Red Cross sponsored a listening session that invited community groups to learn more about emergency preparedness and how to best support the DAFN populations. Many of these organizations signed up to be American Red Cross volunteers so they could better meet the needs of the DAFN populations they served through general education and awareness.

Also following the Thomas Fire, the County noted that there were legal barriers to sharing information about vulnerable populations, including the DAFN community, between county departments during a disaster event. Potentially life-saving information about the whereabouts of individuals receiving In-Home Supportive Services (IHSS), for example, could not be shared with emergency coordinators and responders to ensure safe evacuation. The County attempted to address this situation by pursuing legislation that would authorize county social services agencies to share basic contact information during emergencies but was ultimately not successful due to privacy concerns. More work is clearly needed in this area to ensure the safety of residents under the County's care.

Through its Health Care Coalition, established in January 2014, the Ventura County Public Health Department regularly engages with community organizations that serve individuals with access and functional needs to provide emergency preparedness education and resources so that they may better serve their clients during an emergency. As part of this engagement process, emergency preparedness resources are continuously provided to these community organizations with the request that they share and educate their clients on access and utilization of such resources.

The audit concluded that there was insufficient community engagement in the development of the emergency plans and recommends using a more diverse planning team, including people with a variety of access and functional needs and community organizations that support them. The County acknowledges that an even more inclusive and diverse engagement of community partners, especially a broader range of individuals with disability, access and functional needs in disaster planning will further strengthen our already successful plans and response efforts. To this end, we intend to add additional DAFN representatives to the membership of our EPC and to implement closer coordination with the County Executive Office on planning efforts.

Audit Recommendation: Conduct demographic assessments to identify how many people have access and functional needs, what those needs are, and where those people are generally located.

Gauging the needs of the community is a difficult task since there is no exact methodology for assessing the needs of every member of the population. Using data collected from their clients, the Ventura County Human Services Agency developed and manages a Disaster Preparedness Database with demographic data on clients with DAFN's. This Database is activated prior to anticipated events, (such as severe weather conditions) or at the onset of a disaster/emergency event. Activation includes GIS mapping of the Disaster Database overlays with emergency evacuation/impacted areas to determine potential impacts and/or needs of the DAFN population. The County of Ventura is working collectively to expand upon the existing Ventura County Human Services Agency Disaster Database demographic information to include data from several external sources.

Based upon the information obtained from this database, the County will continue to plan and prepare to assist all Ventura County residents with evacuating during an emergency. This evacuation process includes the rapid dissemination of alert and warning messages in multiple languages, assisting with mass transit services, and leveraging any other County resource needed during a time of need.

The County agrees that an expanded demographic assessment that builds upon the existing assessments conducted by the Human Services Agency will serve to further inform planning associated with DAFN needs during a disaster.

Alert & Warning

Audit Recommendation: Develop alert and warning plans containing strategies to reach all people, including people who have access and functional needs and that ensure that all applicable methods are used to reach individuals.

The County acknowledges that, during the Thomas Fire, we discovered some translation capabilities that could further be enhanced. These findings were quickly addressed during the emergency and continued to be further expanded and improved upon during and after the event, even up to the present. As an example, shortly after the Thomas Fire, the emergency hotline added the capability to provide telephonic translation for 225 languages using Voiance translation services.

There is indeed opportunity to further enhance our alert and warning communications, but we disagree that Ventura County did not prepare adequately to warn residents of impending danger from the Wildfire. The many modes of communication utilized were largely supported in multiple languages, not to mention the fact that no lives were lost or adversely impacted as a result of any communications during any of the disasters included in the scope of the state's audit.

Beyond language assistive support, during the Thomas, Hill and Woolsey Fires, a multi-tiered approach was used to disseminate emergency notifications and information to residents. This approach involved the use of both technological (VC Alert, Wireless Emergency Alerts, Emergency Alert System, Nixle, Social Media, Websites) and human resources (Law Enforcement Door-to-Door Notifications, Public Information Officers, Community Liaisons) to communicate emergency information such as evacuation orders/locations, emergency shelters (human & animal), road closures and other pertinent emergency information. The following describes the multi-tiered methods used in further detail:

Continuing the use of our multi-tiered approach to alert and warning, coupled with continuously expanding our understanding of the communication needs of the DAFN community will help sustain the highly effective alert and warning performance we have experienced during the significant disasters we have experienced.

As background, the County has been proactive in developing best practices in the form of plans, policies, procedures and strategies to best alert and warn Ventura County residents of incidents that pose a threat to health and safety, as demonstrated by the development of an alert and warning plan in 2011 that was approved by the Ventura County Board of Supervisors and entered into formal Memorandum of Understanding agreements (MOUs) with all ten cities in Ventura County. The alert and warning plan outlines industry best practices to send effective and timely emergency notifications to residents during an emergency. This alert and warning plan was last updated in 2017, ensuring Ventura County operated using current industry standard best practices. Ventura County's alert and warning plan was utilized successfully during the Thomas and Woolsey Fires to send over 100 emergency notifications to over 200,000 residents.

In 2018, the California Office of Emergency Services (Cal OES) in partnership with counties throughout the state, began the process of developing the State of California's Alert and Warning Guidelines. Ventura County was an active participant in helping to shape the development of the State's Alert and Warning Guidelines, which was completed in March 2019.

Ventura County is currently in the process of updating the County's Alert and Warning Plan to align with the State's Alert and Warning guidelines document. The Alert and Warning plan will incorporate current industry best practices and local lessons learned from the Thomas and Woolsey Fires.

In support of written alert and warning plans, the County recognizes that clear communication both during emergency and non-emergent events is essential and that communication should extend as far into the community as is reasonably possible in as many ways as possible. For these reasons many of our County agencies currently produce material – both printed and online – in languages other than English. All County websites have translation features. Caseworkers for our Human Services Agency have a real-time, three-way translation service (Stratus Translation software service) that operates through a tablet computer, which enables them to have face-to-face conversations with clients in any language with the translator visible to the client. This same technology was employed at Local Assistance Centers during our recent disasters. The County Executive Office (CEO) acknowledged our communities' needs over a year ago by hiring a full-time, Spanish-speaking Public Information Officer with certified translation abilities. The CEO took this important step as part of a countywide initiative to expand communication with our Spanish-speaking communities. This new position was immediately impactful during the Woolsey Fire, conducting interviews with national Spanish Broadcasters to communicate important emergency information. The Sheriff's Office of Emergency Services utilizes a cadre of Spanish certified translators also serves during emergencies and has additionally engaged a service that can translate documents in one hour or less. The County has developed, and continues to develop further, a cross-agency cadre of translators for Spanish and other languages for use in both emergency and non-emergency situations and maintains relationships with several translation services. Several County agencies and departments that work with underserved communities produce nearly all materials in both English and Spanish. This includes the County's clinic system, Behavioral Health Department, Public Health Department, the Area Agency on Aging and the Human Services Agency.

While not specifically in the context of emergency planning, the County and several of its departments regularly engage with community groups and individuals to hear concerns, share information and resources, and establish relationships of trust. County staff have daily interactions with the community we serve by attending community meetings and events, schools, places of worship and meeting with key community figures. County workers have deep roots, similar ethnic backgrounds, and speak the same language as those we serve and have dedicated themselves to developing trusted relationships with the community and our partners (MICOP, CAUSE, Lideres Campesinas, Proyecto Esperanza, LULAC, One Step a La Vez and various promotoras, just to name a few). County staff provide culturally appropriate services, such as in the Latino community where meeting face-to-face and personal contact is highly effective.

As a result of these community interactions and relationships, during the Thomas Fire, county staff knew the exact organizations and individuals to directly contact when checking in on the needs of those affected in Santa Paula, Ventura and Oxnard. These relationships proved to be effective during the fire when community organizations and community members also knew to directly contact county staff. An example of the importance of these relationships was a request from MICOP who works with a large Mexican indigenous population from Oaxaca that has various dialects and whose native language of Mixteco is neither Spanish nor written. During the Thomas Fire, the CEO Community Liaison had contacted a MICOP representative to share fire information when the representative expressed frustration that a local store had capped the public sale of face masks to individuals and would not sell them in bulk to MICOP, who had planned to distribute the masks to farmworkers and others in the Mixteco community. The CEO Community Liaison immediately contacted the Public Health Director, and he along with his staff, within the hour, delivered face masks to MICOP and United Farmworkers (UFW) for them to distribute. In total, Public Health provided these organizations over 40,000 face masks. These long-running, trusted and personal relationships proved to effectively aid the Spanish-speaking, undocumented and vulnerable members of our community.

During the initial response to the Thomas Fire, public information was primarily distributed by public information officers, the "readyventuracounty" website and the emergency hotline. Each of these methods of information distribution had Spanish translation available. For the Public Information Officers and Hotline, live Spanish speaking translators were available and the "readyventuracounty" website used the "Google Translate" feature, which allowed people to select a variety of languages that directly translates the displayed text. Translation services were provided at all community events and town halls which included the use of wireless translation headphones, including the first Thomas Fire-related event in Ventura on December 9. It is important to note that at the time of the incident, Google translation services on emergency websites were utilized by nearly all emergency operations centers in the state for real time emergency information dissemination in multiple languages, including all of Central and Southern California, and was considered an industry standard. The County recognized this concern with translation and our "readyventuracounty" and "vcemergency" websites were quickly duplicated as actual Spanish text sites by day three of the Thomas Fire. The EOC utilized a certified Spanish translator to update the site in real time during the remainder of the incident. The first bilingual emergency notification/warning was issued via VC Alert on December 14 which was ten days into the incident. All notifications following that were bilingual. Written products, such as press releases, were translated in real time by certified translators or by using the web-based system, One-Hour Translate.

We agree that alert and warning is one of the most important components of emergency planning and are committed to continually seeking ways to reach all people with critical emergency communications.

Audit Recommendation: Create a library of pre-scripted messages for each potential hazard that contains the recommended elements for effective messages and that are translated into the languages most commonly used in the community.

Ventura County agrees with this recommendation and the acknowledgement in the report that this practice is already being followed.

Evacuation Planning

Audit Recommendation: Develop an all-hazard evacuation plan, including strategies for providing evacuation assistance to people with access and functional needs.

Although Ventura County does not presently maintain a universal All Hazards Evacuation Plan, we anticipate formalizing our approach to managing the dynamic evacuation needs of an incident in the form of an evacuation annex to our Emergency Operations Plan.

Over the years, Ventura County has successfully implemented a unique response process that involves immediate coordination between police, fire and emergency management at the scene of an incident. We have found this approach to managing dynamic evacuation scenarios the most effective in terms of flexibility recognizing the one size fits all approach does not work well. Where appropriate, our operational area approach to addressing evacuation needs specific to hazard areas has been to develop, in advance, tactical response guides that are updated on an annual basis, until the hazard subsides. This approach allows stakeholders to ensure these guides are updated regularly and remain consistent with current threat conditions. This "best practice" was implemented by our Operational Area in 2015 following a debris flow threat in Camarillo Springs. Since following this approach, we have successfully been able to evacuate over 200,000 individuals having all manner of needs safely and with remarkably positive outcomes.

Audit Recommendation: Assess the number and locations of people who will need evacuation assistance. Inventory the county's resources to determine its capability to provide that assistance.

The County of Ventura is working collectively to expand upon the existing Ventura County Human Services Agency Disaster Database demographic information to include data from several outside sources. Based upon the information obtained from this database, the County will continue to plan and prepare to assist all Ventura County residents with evacuating during an emergency. This evacuation process includes the rapid dissemination of alert and warning messages in multiple languages, assisting with mass transit services and para-transit resources as needed, and leveraging any other County resource needed during a time of need.

Audit Recommendation: Establish agreements with local transit agencies and other sources of accessible transportation to provide evacuation support.

The County of Ventura maintains several master agreements through the Ventura County General Services Agency Procurement Department for the purposes of establishing transportation services. An example of one such contract was transit services from Roadrunner Shuttle that were successfully utilized during the Thomas Fire to transport DAFN members from shelters to the local assistance center.

In addition to these existing private-sector agreements, numerous Ventura County Agencies are presently engaged with the Ventura County Transportation Commission to complete the Transportation Emergency Preparedness Plan. One of many outcomes anticipated with the completion of this plan is the establishment of MOUs with several transit vendors in our region for the purposes of mass transit during an emergency.


Prior to the Thomas Fire, the County was working with core first responders in the development of a Mass Care and Shelter Plan that included the County's primary partner in emergency sheltering, the American Red Cross. Lessons learned from both the Thomas and Woolsey Fires have helped to better inform this plan that includes recognition of a significant disability, access and functional needs community and the key partners that will be engaged to assist with supporting this community. By incorporating lessons learned from prior incidents, the County also recognizes the need to assist individuals who require communication assistance, specifically those who are deaf or hard of hearing, blind or non-English speaking.

As part of the plan to ensure the rapid identification of community needs following a disaster, the County has trained over 40 functional assessment service team (FAST) workers capable of assessing evacuation shelter conditions. FAST team members work side-by-side with shelter personnel and other emergency response workers to assist in meeting essential functional needs so people can maintain their independence during disasters and emergencies.

Audit Recommendation: Develop sheltering plans that include strategies for ensuring that shelters are accessible to people with access and functional needs.

Following the Thomas Fire and prior to the Woolsey Fire, the County of Ventura embarked upon a lengthy planning process to create a comprehensive Mass Care & Shelter Plan. This process is nearing completion and is slated for publication by January of 2020.

Audit Recommendation: Conduct assessments to determine how many people may seek shelter during natural disasters, how many may have access and functional needs, and what resources the county will need to support them in shelters.

The County of Ventura has and continues to assess the needs of the community, as it relates to emergency sheltering. Due to the complexity of individual needs and living situations, people moving and people dying, there is no exact method for yielding actionable data. We agree in concept with the recommendation but are concerned that the suggested approach in the report may still not result in sufficient actionable information. The alternative of predetermining who will be impacted by any one incident and what their individual needs are, does not yield a fiscally prudent outcome. Instead, the County of Ventura remains focused on a whole community approach, with a goal of being nimble and adaptable as the situation unfolds.

Audit Recommendation: Develop agreements with suppliers for necessary equipment and resources to support shelter residents with access and functional needs.

The County of Ventura maintains numerous master agreements through the General Services Agency Procurement Department for the purposes of procuring equipment and supplies needed for sheltering operations. Though existing master agreements for equipment such as showering, bathing and lavatory equipment did not contain DAFN specific terms, they successfully resulted in the supplies ultimately being available for the DAFN population. While much of this equipment is already owned and maintained by the American Red Cross, the County of Ventura and many of our cities are developing plans to purchase additional shelter equipment to enhance sheltering capabilities. It is believed that with the combination of Red Cross, County, City and private-sector purchasing agreements, securing sheltering supplies in a reasonable timeframe is well within our current response capabilities. It should be noted that existing contracts have successfully provided for the needs associated with sheltering and evacuation assistance of the DAFN population during the disasters we have faced. Nonetheless, the County agrees with this recommendation and welcomes the opportunity to take a second look at our procurement agreements as the audit suggests.

Local Assistance Centers

Audit Recommendation: Develop a plan to ensure local assistance centers are accessible to people with access and functional needs, including by providing accessible notifications about the center, and communication services at the center for those with limited English proficiency or those who are deaf or hard of hearing.

Ventura County has and continues to maintain a Local Assistance Center Plan following the Thomas Fire. Despite not having a plan prior to the Thomas Fire, Ventura County successfully stood up a local assistance center in partnership with the City of Ventura, which provided recovery services to victims of the fire with services and representatives from more than 44 different agencies and non-profit organizations. In part those organizations represented services from the Federal, State, and local governments, as well as faith-based organizations, community-based organizations, including State Department for passports, Department of Motor Vehicles, State Public Health - vital records, Disabled American Veterans, American Red Cross, Salvation Army, Social Security Administration, County Assessor, County homeless and housing services and elected officials to name a few. We acknowledge that our after action report indicated that additional Spanish speaking ambassadors could possibly have been beneficial at the local assistance centers but this is in addition to the ample Bi-lingual staff that were available to provide assistance as were linguistic technology aides such as the Stratus Translation service that was available via tablet devices to meet the diverse communication needs that may have presented at the Local Assistance Center. Overall more than 2,500 individuals visited the Local Assistance Center during the period of time it was operational.

We agree with the audit recommendation and Ventura County will continue to enhance the Local Assistance Center Plan. In an effort to adapt to the changing needs of the community, this plan will be reviewed on a regular interval to ensure adequacy on all levels.

County Recommendations

Audit Recommendation: When planning to protect people with access and functional needs, adhere to the best practices and guidance that FEMA, Cal OES and other relevant authorities have issued.

We are committed to continuous process improvement and in that spirit will continue to pursue best practices when planning to protect people with access and functional needs.

Audit Recommendation: Report publicly to the boards of supervisors during emergency planning about the steps they have taken to address access and functional needs.

As has been our practice and as demonstrated by the recent update provided to our Board concerning our Public Safety Power Shutoff efforts related to medical baseline members of our community, we will continue to share emergency planning efforts with our elected supervisors. It should be noted that a member of our Board of Supervisors also serves as the Chairperson for our Emergency Planning Council.

Audit Recommendation: Consult periodically with a committee of community groups that represent the people with a variety of access and functional needs. Further, Ventura should require that representatives of the community group committees present to the boards of supervisors their review of the adequacy of the emergency plans.

We will continue to conduct the recommended consultations with our community groups and further expand our efforts in this area.

In Conclusion

We appreciate the State Auditor's Office review of our County Emergency Plans for residents with disability, access and functional needs. Our history of successful planning, partnerships and community outreach has resulted in remarkably positive outcomes in some of the most demanding disasters of our time. Notwithstanding, we welcome the State Auditor's review as it gives us an opportunity to further improve our planning and preparations for the future to the benefit of all in our communities.


Bill Ayub
Patrick Maynard
Sheriff OES Staff Emergency Manager
Barry Zimmerman
Human Services Agency Director
Mark Lorenzen
Fire Chief
Michael Powers
County Executive Officer

RESPONSE FROM Ventura County

To provide clarity and perspective, we are commenting on Ventura's response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response.

We disagree with Ventura's assertion that our report does not adequately reflect the actions and steps it has taken to prepare for natural disasters. Our report contains adequate and accurate information related to the areas we reviewed, including both the areas of emergency planning best practices to which Ventura has not adhered and the steps Ventura has taken to address best practices.

Ventura asserts that, during its recent wildfires, no fatalities were attributable to gaps in its emergency planning and preparedness. As we discuss in Chapter 1, we reach no conclusions as to whether any additional lives would have been saved if the county had planned differently or more fully implemented best practices.

During the publication process for the audit report, page numbers shifted. Therefore, the page numbers cited by Ventura in its response do not correspond to the page numbers in the final published audit report.

Although Ventura describes its response actions related to multiple disasters, including the Thomas Fire, we focused our review and conclusions on its emergency planning, and how that planning affected its response to the Thomas Fire.

Ventura states that it is difficult to develop an evacuation plan that addresses all evacuation scenarios. However, this is not the expectation set in FEMA's guidance documents. In fact, FEMA guidance explains that a plan that tries to cover every conceivable condition or that attempts to address every detail will only frustrate, constrain, and confuse those charged with its implementation. Rather, FEMA specifies that these all-hazard plans should include strategies for both no-notice and forewarned evacuations, with particular consideration given to people with access and functional needs. Therefore, we look forward to reviewing Ventura's progress in addressing our recommendation that it develop an all-hazards evacuation plan that aligns with FEMA's best practices during our post-audit follow-up process.

Ventura's reference to four casualties differs from Table 2 in the Introduction, which states that Ventura suffered five fatalities as a result of natural disasters in the last five years. Ventura's total specifically refers to civilian casualties, whereas our total also includes the loss of one first responder.

Ventura states that it has involved response partners and community groups in preplanning activities. Our review found that Ventura did not sufficiently include representatives with diverse access and functional needs when developing its emergency plans and we describe this conclusion in Chapter 1.

Ventura's perception that having a standalone plan for access and functional needs was a Cal OES best practice conflicts with direct advice it received from Cal OES as well as Cal OES's guidance. As we explain earlier, Ventura developed its access and functional needs plan in May 2016 and we explain that Cal OES informed Ventura that having a standalone plan was not advisable. Further, the training Cal OES provides on planning for access and functional needs advises against having a separate plan for these needs.

The assertion that Ventura makes about the access of different county departments to information about vulnerable populations differs from the information it shared with us during our review. Specifically, this assertion contradicts the explanation that Ventura's chief deputy director of human services provided to us—that it makes use of data on people with certain access and functional needs once a disaster occurs and 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. Further, with respect to IHSS clients, the assertion conflicts with the allowance in state law—an allowance that Ventura knew about during our audit—which specifically states that a county department of social services employee may disclose the name and address of elderly or disabled clients to emergency services personnel in the event of an emergency that necessitates a possible evacuation. Therefore, Ventura's response is contrary to state law and to the statements it made to us during our audit.

Although there would be some value in adding representatives with access and functional needs to Ventura's emergency planning council, this step would not implement emergency planning best practices or our recommendation. As we explain in Chapter 1, this council is not involved in developing Ventura's emergency plans. Rather, it is responsible for reviewing and adopting Ventura's emergency plans. 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. By only including these representatives at the review and approval stages of the planning process, Ventura risks that its plans will not adequately address the needs of its whole community.

Ventura misunderstands our recommendation to conduct demographic assessments to better prepare for its community's needs during a natural disaster. We do not recommend that Ventura, or any other county, assess the needs of every member of its population. Rather, as FEMA best practices state, jurisdictions must have an informed estimate of the number and types of individuals with access and functional needs residing in their communities to begin planning. As we describe earlier, 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. 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. These aggregate estimates will allow emergency managers to make more informed decisions about the level of resources they may require during emergencies.

The data included in Ventura's Disaster Preparedness Database is only related to clients of its human services agency. During our review, the chief deputy director explained that this database included IHSS clients and foster children. Ventura has not used this database to assist it in developing its emergency plans, as we explain in Chapter 1. Nonetheless, in its response Ventura indicates that it believes expanded demographic data will help inform its planning. We look forward to reviewing documentation of Ventura's efforts in this area during our post-audit follow-up process.

We stand by our conclusion that, in advance of the Thomas Fire, Ventura did not adequately prepare to warn its residents about impending danger. In Chapter 1 we describe how Ventura had not adequately engaged with persons with access and functional needs during emergency planning, including individuals with limited English proficiency. In addition, as we describe earlier, before the Thomas Fire, Ventura lacked an alert and warning plan and, as we explain earlier, it had not prepared to send life-saving messages in languages other than English despite having a significant population with limited English proficiency. Ventura's opposition to our conclusion is especially disappointing given its recognition in its response that its translation of emergency information on its website and in its alert and warning messages during the Thomas Fire should have been better. Ventura makes a broad claim that the many modes it used to communicate with individuals were largely supported in multiple languages. This claim ignores the significant fact that the evacuation alerts it sent directly to people's landline and cell phones were only sent in the English language until 10 days into the Thomas Fire. Finally, Ventura's own improvements to its alert and warning strategies since the Thomas Fire indicate it believes that it must be better prepared than it was for the Thomas Fire. As we explain earlier, after the Thomas Fire, Ventura developed pre-scripted alert and warning messages in Spanish so that it would be better prepared to warn its residents about impending threats in a language they would understand.

Our report makes no conclusions about whether individuals perished as a result of communication deficiencies. However, Ventura's claim that no lives were adversely impacted due to communications during the Thomas Fire is both impossible to verify and doubtfully true given the large number of individuals in the county who are of limited English proficiency and would not have received alerts in a language they could understand.

Ventura has no alert and warning plan. As we state in Chapter 1, Ventura has standard operating procedures that describe the use of one specific notification system that it uses for sending alert and warning messages. These procedures also specify how the county will partner with cities to issue alerts. Further, Ventura's assertion that this document outlines industry best practices to send effective and timely emergency notifications to residents during an emergency is misleading. The operating procedures discuss only one alerting method and do not address considerations for any of the other methods that Ventura describes in its response. Ventura has since developed a draft alert and warning plan, which it states was developed because of lessons learned in recent disasters. We look forward to reviewing Ventura's finalized alert and warning plan once it has been completed.

Ventura indicates it was engaged with a variety of community groups representing individuals with limited English proficiency before the Thomas Fire. However, it issued evacuation notices during the Thomas Fire in only English, which demonstrates that this community engagement did not influence the way Ventura prepared to alert its residents about lifesaving information. This fact highlights the importance of including such community groups in emergency planning and not relying solely on other interactions the county has with these groups for other purposes.

Ventura is incorrect that all of its emergency notifications and warnings following its initial Spanish message on day 10 of the Thomas Fire were bilingual. After it began issuing Spanish language messages, Ventura issued nine alerts through its emergency notification system. However, Ventura sent only three of these messages with full Spanish translations. A fourth message directed Spanish-speaking recipients who needed information about the Thomas Fire to visit Ventura's website. Ventura sent the remaining messages only in English.

None of these master agreements to which Ventura refers exist for the purpose of providing evacuation assistance, as we explain in Chapter 1. Rather, the master agreements show that local transportation vendors agreed to furnish bus tokens or passes, and none of them referenced how Ventura might leverage these agreements for evacuation assistance during an emergency. We look forward to reviewing the Transportation Emergency Preparedness Plan and accompanying MOUs that Ventura describes in its response as part of our post‑audit follow-up process to determine the extent to which those documents ultimately incorporate best practices for assisting people with access and functional needs during disasters.

Ventura's response acknowledges that it does not maintain agreements for shelter supplies that would ensure that its shelters are fully accessible to those with access and functional needs. However, Ventura expresses its belief that existing agreements that do not specifically contain provisions for obtaining accessible shelter supplies have, nonetheless, been sufficient to address sheltering needs. As we explain earlier, documentation from Ventura showed that it struggled to obtain a sufficient number of accessible cots during the Thomas Fire. Best practices for emergency planning advise emergency management agencies to prearrange for these critical resources so that they are more easily obtained when they are needed. Therefore, Ventura's statement that it will re-examine its existing agreements is a step in the direction of better adherence to best practices for emergency planning.

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California Governor's Office of Emergency Services

October 23, 2019

Elaine M. Howle, State Auditor
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Dear Ms. Howle:

The California Governor's Office of Emergency Services (Cal OES) received the California State Auditor's (CSA) draft report on October 17, 2019, regarding the results of its Emergency Planning Audit (2019-103) (the Report). Cal OES appreciates the opportunity to provide a response. Our rebuttal point #2 references the following text:
On the same day that it received the report, Cal OES requested an accessible version to enable its Chief of the Office of Access and Functional Needs to review the document with greater ease. In response, CSA stated that it had no obligation to furnish an accessible report. CSA then refused to provide an accessible report unless Cal OES agreed to additional conditions, over and above Cal OES' legal obligations, related to document disposal. Rather than negotiate terms for the release of an accessible report, Cal OES made its own in-house accommodations.

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

According to the Report, "Cal OES has not followed a critical best practice: involving individuals with access and functional needs" in the State Emergency Management System (SEMS) committees and in other planning groups. This statement is inaccurate and counterproductive.

In point of fact, Cal OES partners with, includes, and coordinates with individuals and representatives from the access and functional needs (AFN) community on the development of every major product, tool, guidance, plan, lesson learned, finding, and initiative. As a pioneer of AFN considerations in emergency management, Cal OES recognized early on that, nationwide, individuals with access and functional needs have historically been excluded from the emergency management planning process. That marginalization led to significant planning gaps measurable in human suffering and lives lost. It also engendered a deep mistrust within the AFN community towards local, state, and federal emergency management agencies.

To address this challenge, Cal OES took groundbreaking action in 2008 by creating an Office of Access and Functional Needs (OAFN) to identify and integrate whole community needs before, during, and after disasters. In recognition of this Office's importance, Cal OES ensured that the chief of OAFN would be a gubernatorial appointee, supported by his or her own staff, and reporting directly to Cal OES' executive office. This action was unprecedented, and today California remains the only state with such a senior level executive leading an entire office dedicated exclusively to AFN considerations.

Cal OES agrees with the Report's premise that AFN representation across the SEMS committees is important, but disagrees with the notion that our current approach of "placing the same individual—the chief of its Office of Access and Functional Needs—on six of the seven committees" derogates from a whole community approach to planning. The Chief of OAFN is both a subject matter expert in emergency management and an individual with the experience of a lived access and functional need. As a substantive expert and a statewide leader whose reach extends across AFN communities, the Chief represents both the community to emergency managers, and emergency managers to the community.

The Report's narrow focus on committee representation causes it to miss the forest for the trees. By focusing narrowly on the makeup of the (largely ad hoc) SEMS committees, the Report neglects the myriad of ways in which Cal OES incorporates AFN communities, and AFN considerations, into a whole community approach to planning. In addition to SEMS, the Chief of OAFN remains in daily contact with AFN stakeholders throughout California, including the community based organizations (CBOs) that form a key part of protecting individuals with access and functional needs before, during, and after disasters. Similarly, Cal OES' regional staff are in frequent contact with the CBOs that represent the AFN community in their areas.

Further, by focusing on questions of representation, the Report threatens to tokenize AFN community participation in SEMS and other planning groups. To mandate the appointment of "individuals with the full range of access and functional needs" on planning groups is an unnecessarily rigid step. Such a tokenistic approach would only serve to undermine the hard-won social progress that Cal OES has helped to lead in conceptually desegregating AFN considerations—debunking the notion that AFN considerations are separate and apart from planning—and incorporating AFN into every element of the planning process. Our rebuttal point #7 references the following text:
CSA repeatedly declined invitations to join the Chief of OAFN at his frequent community engagement events throughout the state. Further, it appears that CSA neglected to contact the major CBOs that engage with Cal OES on AFN considerations.

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

a. Incorporation of Best Practices Related to AFN into the State Emergency Plan

The Report notes that "[i]n 2013, the Legislature amended state law to require Cal OES to update the [California State Emergency Plan (SEP)] to include proposed best practices for local governments and nongovernmental entities to use to mobilize and evacuate people with disabilities and others with access and functional needs." According to the Report, "Cal OES did not make these changes and the [SEP] 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."

In making this claim, the Report misunderstands how emergency plans in general, and the SEP in particular, function within California's emergency preparedness framework. The SEP does not include a list of best practices. Rather, it sets forth a framework that reflects best practices in a manner that is sufficiently general to enable emergency managers to respond to all hazards. Consistent with this approach, the current SEP does not segregate AFN considerations in a single section, or relegate them to an appendix. Rather, it addresses AFN considerations throughout the entirety of the document, using terms like "access and functional needs," "AFN," and "disability" over two dozen times, including with reference to evacuation. Even when the SEP does not use these terms, it incorporates and reflects best practices related to the protection of socially vulnerable populations.

The Report prominently references the Congressionally enacted Post-Katrina Emergency Management Reform Act (PKEMRA) of 2006. In doing so, the Report underscores the degree to which California has been a pioneer in incorporating AFN considerations into its planning. Particularly, the Report cites PKEMRA as a driving force for "provisions to improve planning to meet access and functional needs." PKEMRA also changed the way the Federal Emergency Management Agency (FEMA) and the federal government approached emergency management.

Based on PKEMRA, in March of 2008, the National Response Framework (NRF) replaced the National Response Plan (NRP) setting forth a national standard for framework design that came into alignment with the SEP, which was already well under development at the time. The SEP was also the foundation of California's accreditation from the Emergency Management Accreditation Program (EMAP), the premier national standard for emergency management programs.

Parallels between the National Framework and California SEP are not accidental, as California has consistently modeled the way for emergency management and plan development, just as California's Standardized Emergency Management System (SEMS), established in1993, was replicated nationally through the National Incident Management System (NIMS) in 2003.

As evidenced by its organization, plans, and actions, Cal OES has been a leader in changing the discourse from one that segregates and tokenizes AFN considerations, to one that incorporates AFN considerations across all areas. In short, consistent with Cal OES' pioneering efforts, the SEP reflects AFN considerations throughout its text.

b. The Use of, and Advice to Local Jurisdictions about, Disaster Registries

The Report states that "Cal OES has not fully complied with a state law related to the establishment of disaster registries." Cal OES is not required to, nor does it, maintain a disaster registry. Cal OES has determined that disaster registries are themselves not a best practice. Among other problems, disaster registries raise privacy concerns, and are unlikely to contain complete, updated, and accurate information since they are a voluntary, opt-in system. These registries may also give a false sense of assurance that, for instance, an individual who opts in to the registry will be afforded particular evacuation assistance. This could be problematic during a disaster.

Cal OES believes there are better approaches to engaging the AFN community, such as coordinating through CBOs. Accordingly, Cal OES has not itself developed a statewide registry, and its guidance to counties is not to use them. However, when counties wish to use such registries, Cal OES has provided, and continues to provide, advice and guidance on considerations local governments should be aware of with regard to these registries. In addition to providing guidance to local government on a frequent basis via day-to-day interaction, Cal OES has published on its website guidance specific to disaster registries.

Additionally, the report indicates, "[t]o the extent that any 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." This assertion is at best speculative and at worst incorrect. Cal OES has always provided feedback, guidance, and technical assistance to local government agencies indicating a desire to use such a registry. To conclude that Cal OES "failed to fulfill its mission" is misguided, exaggerated, and fails to recognize the nearly constant and regular support and guidance Cal OES provides to local governments throughout the state in the context of access and functional needs in disasters.

c. Translated Message Templates

During the audit process, CSA informed Cal OES that state law required it to "create a library of translated emergency notifications that may be used by designated alerting authorities when issuing emergency notifications." Cal. Gov. Code § 8594.16(b). Although statute requires Cal OES to "consider the two most commonly spoken languages other than English in the state when creating the library," id., CSA suggested shortly before completing its draft report that Cal OES should create message templates in 15 languages. Cal OES then created a style guide, as well as a message templates in 19 languages. Those languages are:

  1. English
  2. Spanish
  3. Chinese Mandarin
  4. Chinese Cantonese
  5. Vietnamese
  6. Tagalog
  7. Korean
  8. Armenian
  9. Russian
  10. Farsi
  11. Japanese
  12. Arabic
  13. Mon-Khmer/Cambodian
  14. Hmong
  15. Laotian
  16. Punjabi
  17. Hindi
  18. Thai
  19. Portuguese

After Cal OES completed these templates, CSA did not engage with Cal OES to address further concerns. Rather, CSA revised their Report, adding new critiques without Cal OES' input, concluding that Cal OES' 19 templates were "marked by deficiencies."

CSA's rush to judgment is reflected in the quality of its product. Most significant, the purported "deficiencies" correspond to operational and tactical considerations best left to the sound discretion of emergency management professionals working in a dynamic environment. As noted below, rather than address here the critiques as set forth in the Report, Cal OES will engage with local jurisdictions and emergency management professionals with competent experience to determine the most operationally sound approach to enhancing the effectiveness of translated message templates.

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

The Report notes that Cal OES has developed a large volume of information ("almost 250 links to different websites and documents") as well as web-based tools, "for local jurisdictions to use in their emergency planning, including their planning to meet access and functional needs." The Report suggests that these tools and information could be better organized. While Cal OES is committed to making its webpages easy to navigate, the Report's suggestions largely miss the mark.

As the Report alludes, Cal OES has curated a large volume of AFN resources that are centrally located and free for local jurisdictions and other stakeholders to use. These resources include everything from guidance documents and "lessons learned" products to innovative tools such as the Cal OES Access and Functional Needs Web Map. Indeed, the Web Map is an illustrative example of the innovation that Cal OES has advanced as a pioneer in the AFN space. A first-of-its kind initiative, the Web Map deploys Geographic Information System mapping technology to overlay geographic data on active threats (such as fires), alongside the location of shelters and warming/cooling stations, assets that the AFN community can use in an emergency (such as accessible transportation and accessible hygiene resources), as well as county-level Census data on the AFN community. Not only is this resource instructive to members of the AFN community, it assists emergency managers in all of California's 58 counties in identifying, locating, and deploying AFN related assets during all phases of an emergency.

After making note of the sheer volume of AFN resources that Cal OES has compiled, the Report correctly observes that Cal OES "does not indicate" which resources are the "most valuable for local jurisdictions." Nor would Cal OES ever do so, for at least two reasons. First, local jurisdictions are better placed to determine which resources are most useful to them. Second, each local jurisdiction has unique needs, making it infeasible for Cal OES to impose a single, endorsed list of "best" resources applicable to all of California's 58 counties.

Further critiquing Cal OES' webpage, the Report suggests Cal OES "has not made those [AFN] resources easily available to the local jurisdictions." While Cal OES again agrees that its website can be improved, it is false to suggest that an imperfect website means Cal OES has not made informational resources available to local jurisdictions. Cal OES, most often through OAFN, notifies jurisdictions across the state regarding new inclusive planning products via a multiplicity of methods such as email, presentations at meetings (conferences, regional events, Mutual Aid Regional Advisory Committees [MARACs], etc.), outreach through each region, direct contact, articles in newsletters, and other means.

4. "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"

The Report notes that Cal OES has not completed its after-action reports (AARs) in a timely manner. Relying on this observation as a premise, the Report goes on to state that Cal OES has failed to share lessons learned from recent disasters with local jurisdictions. While the Report's premise is accurate, its conclusion could not be more wrong.

Before CSA began its audit, Cal OES identified the backlog in its AARs. The principal reason for this backlog is that recent disasters have sharply elevated Cal OES' workload. Cal OES is configured such that its "steady state" staff also comprise its surge capacity; the same personnel who draft AARs also support disaster response and recovery activities. As disasters increase in scale, complexity, and frequency, there are more AARs to complete, yet fewer staff to complete them.

The sheer volume of Cal OES' disaster-related work is hard to overstate. As the Report itself notes, from January 2014 through December 2018, there were no fewer than 61 gubernatorially declared disasters in California. In 2017, after dealing with six years of unprecedented drought conditions, California experienced record rainfalls that resulted in Presidential Disaster declarations in 53 of California's 58 counties. The failure of Oroville Dam spillway resulted in the largest non-hurricane evacuation in U.S. history. The 2018 calendar year brought the largest, deadliest, and most damaging fires in the state's history. By the end of 2018, wildfires in California killed over 120 people, destroyed more than 22,700 structures, and burned over 1.8 million acres. Ten of California's most destructive fires have occurred since 2015, with four of the largest wildfires occurring since 2017. California's deadliest wildfire leveled nearly the entire city of Paradise in 2018, killing 86 people; the cleanup, rebuilding, and full economic recovery for this fire alone could span a decade. In July 2019, a 6.4 magnitude foreshock, and 7.1 magnitude earthquake, struck near Ridgecrest—the most powerful earthquake in California in nearly 20 years.

To adapt to the task of completing AARs while simultaneously addressing the response and recovery needs that result from this unprecedented series of disasters, Cal OES has implemented a new AAR process. The new system is being utilized on both backlogged AARs and new disasters beginning in 2019. As the Report notes, statute requires that Cal OES provide these AARs to all "interested emergency management and public organizations," and Cal OES does so.

However, these gaps in the AAR process do not mean Cal OES has failed to share lessons learned from recent disasters with local jurisdictions. Indeed, in focusing on Cal OES' formal AAR process, the Report fails to recognize the myriad of debriefs, hot washes, and other feedback loops designed to continually improve California's emergency management processes and educate local government on best practices. For example, the very exercise of developing an AAR requires Cal OES and local jurisdictions to engage in a critical dialogue that enriches the understanding of both Cal OES and the jurisdictions themselves. In practice, these critical dialogues begin immediately after—if not during—a disaster. Furthermore, as the Report itself notes, Cal OES engages with operational areas through MARAC meetings where Cal OES and local government regularly discuss and share best practices. The MARACs, as part of the SEMS Maintenance System, can escalate collective emergency management concerns and initiate improvements statewide with or without an AAR.

Finally, in focusing on formal structures and documentation—the Report's discussion MARAC minutes is a notable example—the CSA neglects to credit Cal OES' constant communication with all operational areas before, during, and after disasters about best practices and lessons learned. These nearly real-time processes are just as important—if not more important—than the formal AAR process in ensuring that lessons are learned and shared throughout California.

CSA Recommendation:

To ensure 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.

Corrective Action by Cal OES:

Cal OES will issue formal guidance regarding disaster registries. For the reasons described above, Cal OES will not change its approach to SEP but will continue to reflect AFN considerations throughout all of its planning documents.

CSA Recommendation:

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:

Corrective Action by Cal OES:

Cal OES notes that it is in full compliance with the law governing translated message templates. As noted above, Cal OES will engage with emergency management professionals, as well as with local jurisdictions, to determine the most operationally sound approach to enhancing the effectiveness of translated message templates.

CSA Recommendation:

To improve local jurisdictions' ability to quickly access 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.

Corrective Action by Cal OES:

Cal OES will continue to improve the AFN resources provided through all channels on an ongoing basis.

Cal OES appreciates the assistance and guidance offered during CSA's audit. Should you have additional questions or concerns, please contact Ralph Zavala, Cal OES Internal Audits Office Chief, at (916) 845-8437.




cc: Christina Curry, Acting Chief Deputy Director
Timothy Perry, Chief of Staff
Eric Lamoureux, Acting Deputy Director, Response
Vance Taylor, Chief, Office of Access and Functional Needs
Ralph Zavala, Chief, Internal Audits Office


CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM the California Governor's Office of Emergency Services

To provide clarity and perspective, we are commenting on Cal OES's response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response.

Cal OES asserts that our conclusions about the extent to which it included individuals with access and functional needs in its planning groups are inaccurate and counterproductive. They are neither. Our findings are supported by sufficient and appropriate evidence, and our report makes clear the consequences of Cal OES failing to follow state law and best practices. As we indicate in Chapter 2, state law requires Cal OES to include, to the extent practicable, 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. At no point during our audit did Cal OES argue that such participation was not practicable. Therefore, in disregarding our findings, Cal OES ignores best practices and its statutory obligation to include key individuals on its committees.

In addition, Cal OES's own guidance states that successful emergency planning depends on involving representatives of people with access and functional needs when strategies are considered and plans are developed, which it refers to as "having the right people at the table." Cal OES guidance further states that it is important to recognize that emergency preparedness, response, and recovery involves the entire community, therefore a broad spectrum of the community should have a voice at the planning table. As we describe earlier, contrary to requirements in state law and to its own guidance, Cal OES included only one representative of people with access and functional needs on its committees—the chief of the Office of Access and Functional Needs (chief)—who is not representative of all access and functional needs populations. Including only this one individual does not give voice to a broad spectrum of the access and functional needs community during planning, and risks not adequately addressing the needs of those in that community.

Finally, Cal OES's failure to comply with state law and implement best practices can have significant detrimental effects. As we note in Chapter 2, when Cal OES fails to include diverse representation in its emergency planning efforts, the risk is higher that local jurisdictions will not believe that the practice is worthwhile for their own planning efforts. Cal OES also risks not sufficiently addressing access and functional needs in its guidance for local jurisdictions when it does not adequately include representatives of people with those needs in its development. Local jurisdictions should be able to rely on Cal OES's guidance regarding what to include in their emergency plans. As we state earlier, if Cal OES's guidance does not fully address access and functional needs, local jurisdictions' plans are also less likely to do so.

State law requires Cal OES to provide accessible information to its employees, which would include a copy of our draft report. Regardless, we attempted to assist Cal OES in accomodating its employee while complying with confidentiality requirements under state law that we must maintain. That law requires that all substantive communications relating to an ongoing audit are confidential, including draft copies of our reports; dissemination to unauthorized individuals is a misdemeanor. Therefore, we maintain strict security protocols, including control of hard copies of our draft report that we provide to auditees, and we ask them to do the same. In response to Cal OES's request, we agreed to depart from our usual practice and provide an electronic draft copy for Cal OES's review. The only "condition" we applied to providing the electronic copy was related to the secure disposal of that copy. Specifically, in order to have reasonable assurance that this confidential, but now easily disseminated electronic document had remained secure, our legal counsel contacted Cal OES' chief counsel to request that at the end of the 5-day review period the chief counsel provide us with a written statement that all electronic and hard copies had been deleted or destroyed. The chief counsel refused to provide this assurance and thus we declined to provide an electronic draft copy of the report.

We agree that the chief is a subject matter expert regarding access and functional needs. However, as we note earlier, despite that subject matter expertise, the chief cannot provide the same depth of insight on specific access or functional needs as people with those needs or their representatives can provide. As we list in the Introduction, under state law individuals can have access and functional needs due to:

Further, Cal OES's perspective is in conflict with the chief's statements to us during the audit. As we note earlier, the chief expressed his belief 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.

Cal OES attempts to minimize its failure to adequately include individuals with access and functional needs on its committees by stating our review had a "narrow focus." By doing so, Cal OES downplays the critical functions that its committees perform. To the contrary, the committees we reviewed are responsible for the formation of the guidance that local jurisdictions throughout the State rely on to know how to conduct their emergency planning and response activities. For example, one committee we reviewed was responsible for developing the State's guidelines on alert and warning messages—messages that frequently contain life-saving information. The importance of this committee's work is reinforced by state law, which authorizes Cal OES to impose conditions on local jurisdictions' receipt of grant funding unless they operate their alert and warning activities in a manner consistent with those guidelines. Further, we observed that the three counties we reviewed were waiting for Cal OES to publish its alert and warning guidelines before adopting changes to their own plans. In other words, the actions of Cal OES's committees can have a profound effect on local jurisdictions' emergency planning and management. Therefore, it is imperative that Cal OES ensure that those committees adequately integrate representatives of people with access and functional needs by including them as members of its committees.

Cal OES's comment on including people with access and functional needs in its planning is disconcerting. FEMA and Cal OES guidance indicate a broad diversity of perspectives is critical to a planning process. These best practices were the basis of our recommendation that the Legislature require Cal OES to include representatives of people with access and functional needs on its planning committees. By claiming that our recommendation would promote "tokenism"—the act of making only a symbolic or perfunctory effort to perform a task—Cal OES implies that these representatives would provide no actual value to its planning processes, a position at odds with its assertion of being a pioneer of access and functional needs considerations in emergency planning. Also, it is dismaying to see Cal OES indicate that this kind of representation on its committees would somehow serve to undermine the position of people with access and functional needs. Finally, Cal OES presents no clear reconciliation of its best practice advice to local jurisdictions to include a broadly diverse group in emergency planning, the recently-created requirement in state law for local jurisdictions to follow that best practice, and its apparent belief that our recommendation to do the same thing at the State level is inadvisable and unnecessarily rigid.

Throughout its response, Cal OES attempts to distract from our conclusions that it failed to follow state law by suggesting we do not understand the subject matter of this audit and by minimizing the importance of following state law. The fact that Cal OES has not complied with key state laws related to access and functional needs is clear and undeniable, as we demonstrate throughout Chapter 2 of our report. Despite the various objections that it includes in its response, Cal OES does not have authority to decide whether to comply with state law. Our report makes clear the effects of Cal OES's noncompliance: local jurisdictions are without the important guidance that the Legislature and the Governor intended that Cal OES provide to them.

Cal OES appears to suggest that there was a gap in our analysis because we did not attend its community events or have discussions with community based organizations with which it claims to partner. During our audit we were aware of the chief's community events and Cal OES's assertions that it has discussions with community based organizations. Consistent with the standards we are required to follow and our approach to all audits, we used our professional judgment to determine the procedures necessary to obtain sufficient and appropriate evidence to support our conclusions. For instance, we reviewed Cal OES's alert and warning guidelines and requested documentation to support that Cal OES had involved representatives of people with access and functional needs in the development of those guidelines. Cal OES was unable to provide that documentation, and as we discuss in Chapter 2, the alert and warning guidelines do not adequately address strategies for meeting access and functional needs. Therefore, despite the chief's attendance at community events and the claims Cal OES makes that it engages with major community based organizations, it did not adequately involve those groups in the development of the alert and warning guidelines, which ultimately affected the quality of those guidelines. Therefore, we stand by our conclusions.

Cal OES raises matters that are unrelated to the requirement in state law or the conclusion we present in our report about its failure to comply with state law requiring it to provide certain guidance to local jurisdictions. State law does not require Cal OES to segregate access and functional needs considerations or relegate them to an appendix, and our report does not say that Cal OES should do so.

In the Introduction to our report we present the fact that in 2006 Congress and the President created the Post Katrina Emergency Management Reform Act, which called on FEMA and state and local emergency response agencies to more sufficiently address access and functional needs in the preparation for and response to natural disasters. We also note that, in 2008, California created the Office of Access and Functional Needs at Cal OES. However, as we detail in Chapter 2 of our report, there have been critical deficiencies in Cal OES's leadership and its support of local jurisdictions related to planning to protect and assist people with access and functional needs.

Contrary to Cal OES's statement, our report does not suggest that it is required to or should maintain a disaster registry. Rather, our report describes that state law requires Cal OES to develop model guidelines for local jurisdictions that intend to develop disaster registry programs, including recommendations for addressing known problems with the use of disaster registries. However, Cal OES failed to develop that guidance as state law requires.

The guidance that Cal OES describes is inadequate because it does not meet the requirements in state law. We discuss in that section that state law requires Cal OES to develop model guidelines on disaster registries, including recommendations for addressing known problems with the use of disaster registries, such as maintaining privacy for the people on the registry, and 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, as we also discuss in our report, the guidance that Cal OES has issued about disaster registries does not contain all of the information that state law requires. Instead, it states that registries have proven unworkable, generally emphasizes concerns about registries, and provides little advice about how a local jurisdiction should manage a registry.

Cal OES takes our conclusion out of context and then states that it is misguided, exaggerated, and fails to recognize the actions it has taken to support local jurisdictions. Our conclusions are not misguided or exaggerated and the support that Cal OES provides to local jurisdictions does not excuse its failure to follow state law. Since 1991, state law has required Cal OES to provide guidance on disaster registries and our review found that it has not done so. To fully satisfy its mission to support local jurisdictions, Cal OES should provide all statutorily required support to local jurisdictions. Therefore, because it has not provided the required guidance, Cal OES has not fulfilled its mission. We also note that later in its response, Cal OES agrees that it should follow state law and issue guidance on disaster registries. We look forward to reviewing documentation of its efforts as part of our post-audit follow up process.

There is significant context missing from Cal OES's response. Over the course of this audit, Cal OES had ample opportunity to discuss these templates with us but chose not to do so. As we state in Chapter 2, we repeatedly asked Cal OES about its plan for developing these statutorily required templates and a translation style guide. We first requested this information in May 2019, and for several months Cal OES staff did not articulate such a plan. After we told Cal OES that we planned to report that it had no plan for producing the required templates and style guide, Cal OES finally responded. Specifically, in mid-September 2019, Cal OES claimed that it had contracted with a translation firm for the purposes of fulfilling this requirement. When we asked for a copy of this contract, Cal OES did not provide it.

In late September 2019 we met with Cal OES to share a draft of our audit report and at that meeting Cal OES informed us that it had posted Spanish language message templates to its website and that it was developing Chinese language templates. During the meeting Cal OES shared no plan for developing a translation style guide or templates in any other languages. Shortly after that meeting, while we were preparing the final draft report for Cal OES's review, Cal OES notified us that it had posted message templates in 19 languages and a translation style guide to its website. We reviewed the templates and style guide and made revisions to our draft report before providing it to Cal OES for its review. Subsequently, we contacted Cal OES multiple times to inquire as to any concerns it had about our conclusions. However, Cal OES never raised concerns about our conclusions concerning its message templates and translation style guide.

Cal OES dismisses the deficiencies that we identified in its message templates and translation style guide but does not explain what specifically about our critiques it takes issue with. The deficiencies that we identified in the message templates are irrefutable and, as we describe earlier, render the message templates largely unhelpful to local jurisdictions. We further state in our report that these deficiencies increase the risk that local jurisdictions will not use the templates or use the wrong message template in an emergency situation. We encourage Cal OES to follow through on its pledge to work with local emergency managers to enhance the effectiveness of its templates, although partnering with local jurisdictions is something that we would have hoped Cal OES had done in advance of releasing these templates. We look forward to reviewing documentation of Cal OES's engagement with local jurisdictions to improve its message templates and translation style guide.

Cal OES does not explain why it thinks our recommendation to make its guidance and resources easily available misses the mark. As we state in Chapter 2, Cal OES's own chief acknowledged that the access and functional needs library could be improved so that local jurisdictions can more easily navigate it, and indicated that Cal OES would seek a contract to restructure and improve the webpage.

Cal OES also suggests that it would not recommend valuable resources to local jurisdictions because of each local jurisdiction's unique needs. In doing so, Cal OES ignores that—although local jurisdictions needs may vary—there are key sources of planning best practices that are beneficial for all local jurisdictions. For instance, FEMA has published several major guidance documents related to alert and warning, evacuation, and sheltering, which we reference in our report. Cal OES also ignores that some of the almost 250 documents on its webpage are simply not relevant for most local jurisdictions, such as the guidance directed at hospitals or polling places that we reference earlier. Local jurisdictions should not have to search a webpage containing irrelevant guidance to find key sources of planning guidance.

Cal OES acknowledges in its response that it has not complied with state law related to the timely completion of after-action reports. As we discuss in Chapter 2, Cal OES is uniquely positioned to identify local jurisdictions' successes and struggles in responding to emergencies, and share that information with local jurisdictions across the State to help them in their planning. However, Cal OES has not completed after action reports for the vast majority of natural disasters that have occurred in the last five years, and it has not broadly disseminated lessons learned from those disasters. In its response, Cal OES restates perspective that it provided during our audit that it has shared lessons from recent disasters at various in-person meetings. We note this perspective earlier, and state that we reviewed minutes from the meetings at which Cal OES claimed that it shared lessons learned. Although the minutes indicated 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. Moreover, these discussions are a poor substitute for the broader and more complete perspective that after-action reports are intended to provide. As we state in that same section, by not widely publicizing lessons learned from recent disasters—through after-action reports or any other means to disseminate those lessons—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.

In its response, Cal OES indicates resource constraints are the reason why it has been unable to complete timely after-action reports in accordance with state law. However, Cal OES did not provide this explanation to us during our audit. Rather, our report contains the two reasons for delayed and incomplete after-action reports that Cal OES provided during our review: its belief that state law is unclear as to when those reports are due and that local jurisdictions do not always submit their own after-action reports to Cal OES. Because it did not share information about resource constraints with us, we have no assessment on the degree to which resource availability is a sufficient explanation for Cal OES's failure to complete after-action reports. However, we do note that even though Cal OES considers resources to be a constraint for it in completing after-action reports, its response does not indicate any actions on its part to reallocate or seek additional resources to address this constraint.

We note Cal OES's adoption of a new after-action report process in March 2019 but also note that as of October 2019, Cal OES had not issued any after-action reports using that process.

In declining to implement our recommendation to issue the guidance on evacuating people with access and functional needs, Cal OES indicates that it does not intend to fulfill its statutory obligation to do so. As we note in comment 6, Cal OES does not have the authority to choose whether to comply with state law.

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