Report 2017-119 All Recommendation Responses

Report 2017-119: California State University: It Has Not Provided Adequate Oversight of the Safety of Employees and Students Who Work With Hazardous Materials (Release Date: April 2018)

Recommendation #1 To: University, California State

To ensure that it provides effective oversight of health and safety issues on the campuses, the Chancellor's Office should, by September 2018, review and identify all recommendations issued to the Chancellor's Office and the campuses from the University Auditor's systemwide audits of campus health and safety practices since 1994.

60-Day Agency Response

In May 2018, we reviewed, identified, and summarized all recommendations from the division of Audit and Advisory Servicesı related to campus health and safety practices since 1994.

ıThe "Office of the University Auditor" has been renamed and is now the division of Audit and Advisory Services; the University Auditor is now the Vice Chancellor and Chief Audit Officer.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #2 To: University, California State

To ensure that it provides effective oversight of health and safety issues on the campuses, the Chancellor's Office should, using the information from recommendation 1, develop and implement a plan by January 2019 to ensure that the campuses have taken appropriate actions to comply with health and safety requirements.

1-Year Agency Response

The division of Audit and Advisory Services developed and began implementation of an audit plan to conduct health and safety audits at all the campuses. The four campuses that were part of this audit will receive a review of their implementation of the recommendations as opposed to another full audit. As of April 2019, preliminary draft reports have been sent to two campuses, report writing is in process for three campuses, fieldwork is in process at seven campuses, and the Chancellor's Office and remaining eleven campuses are scheduled to start during 2019.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

The Chancellor's Office provided evidence demonstrating that is implementing an audit plan to audit campuses to ensure that the campuses have taken appropriate actions to comply with health and safety requirements. To the extent that it fully executes this plan, the Chancellor's Office will have fully addressed this recommendation.

6-Month Agency Response

In May 2018, we reviewed, identified, and summarized all recommendations from the division of Audit and Advisory Servicesı related to campus health and safety practices since 1994. We are currently in the process of using this information to develop an audit plan and in January 2019, we expect to begin conducting health and safety audits at all the campuses. The four campuses that were part of this audit will be the last ones visited and the visits will consist of a review of the campuses' implementation of the recommendations from this audit.

ıThe "Office of the University Auditor" has been renamed and is now the division of Audit and Advisory Services; the University Auditor is now the Vice Chancellor and Chief Audit Officer.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

In May 2018, we reviewed, identified, and summarized all recommendations from the division of Audit and Advisory Servicesı related to campus health and safety practices since 1994. We are currently in the process of using this information to develop an audit plan and in January 2019, we expect to begin conducting health and safety audits at all the campuses. The four campuses that were part of this audit will be the last ones visited and the visits will consist of a review of the campuses' implementation of the recommendations from this audit.

ıThe "Office of the University Auditor" has been renamed and is now the division of Audit and Advisory Services; the University Auditor is now the Vice Chancellor and Chief Audit Officer.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #3 To: University, California State

To ensure that it provides effective oversight of health and safety issues on the campuses, the Chancellor's Office should, by November 2018, develop a uniform health and safety reporting template and require the campuses to use it to annually report information related to campus health and safety, including data regarding employee and student training and any other areas the Chancellor's Office considers critical to its oversight of health and safety compliance. In developing this reporting template, the Chancellor's Office should consider the information from its own health and safety-related audits as well as the findings and recommendations of this audit.

Annual Follow-Up Agency Response From October 2019

As confirmed by the State Auditor, the Chancellor's Office provided evidence demonstrating that it developed a uniform health and safety reporting template and required the campuses to use it to annually report information related to campus health and safety, including data regarding employee and student training and other areas the Chancellor's Office considers critical to its oversight of health and safety compliance. In October 2019, the Chancellor's Office updated the reporting template to include a comparison of the number of students and employees required to receive required training to address whether the training is adequate.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

1-Year Agency Response

The Chancellor's Office has completed a uniform health and safety reporting template and distributed it to campus environmental health and safety directors. Campuses can use either the template or their own report format, as long as the reports include the required data, though we encourage campuses to use the standardized reporting template.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

The Chancellor's Office provided evidence demonstrating that it developed a uniform health and safety reporting template and required the campuses to use it to annually report information related to campus health and safety, including data regarding employee and student training and other areas the Chancellor's Office considers critical to its oversight of health and safety compliance. It also provided evidence demonstrating that it considered information from its own health and safety-related audits as well as findings and recommendations of this audit.

However, although the new reporting template includes data regarding employee and student training, it does not address whether the training is adequate. Specifically, it only identifies the number of students and employees trained and does not include a comparison of the number of students and employees required to receive required training.

6-Month Agency Response

The Chancellor's Office is in the process of finalizing a uniform health and safety reporting template for the campuses to use to report information on health and safety, including data regarding employee and student training and other areas we consider critical to oversight of health and safety compliance. We expect the template to be complete in November 2018. In addition, we have gone a step further by updating existing policy to provide a framework for administrative environmental health and safety processes, assessment, and reporting.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

In May 2018, we compiled a list of all recommendations from past audits by the division of Audit and Advisory Services. Using this information, as well as the findings and recommendations from this audit, the Chancellor's Office is in the process of developing a uniform health and safety reporting template for the campuses to use to report information on health and safety, including data regarding employee and student training and other areas we consider critical to oversight of health and safety compliance.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #4 To: University, California State

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should assess the data and information in the reports to identify trends, risks, and best practices.

Annual Follow-Up Agency Response From October 2020

Campuses submitted their reports in late 2019. The responses were assessed by Systemwide Risk Management at the Chancellor's Office to identify trends, risks, and best practices. Further, several recommendations for improving the process were also made. The results were presented to the campus Environmental Health & Safety Directors Affinity Group in January 2020. In addition, improvements have been made to the annual reporting template to provide more comparable data in the future.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #5 To: University, California State

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should develop recommendations for improving campus health and safety and follow up on the campuses' implementation of any corrective actions related to these recommendations.

Annual Follow-Up Agency Response From October 2021

Systemwide Risk Management received and evaluated the information in the 2020 annual reports and made recommendations to the campuses.

The Chancellor's Office follows up on the campuses' implementation of corrective actions via the annual reporting process. In addition, a report was presented to the Chief Administrators and Business Officers affinity group in June 2021 and administrators were asked to follow up on the campus-specific findings and recommendations.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2020

Campuses submitted their first reports in late 2019. The responses were assessed by Systemwide Risk Management at the Chancellor's Office and results were presented to Environmental Health and Safety Directors Affinity Group in January 2020. Recommendations for improving campus health and safety were included in the presentation. Systemwide Risk Management will follow up with campuses to evaluate implementation of any corrective actions related to these recommendations once they receive the responses to the 2020 annual reports, which are due in November 2020.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2019

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation. In addition, a new Systemwide Environmental Health and Safety Manager started work at the Chancellor's Office on December 17, 2018; his duties include consulting with the campuses as well as conducting follow up on compliance issues.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation. In addition, the Chancellor's Office is in the final stages of recruiting a Systemwide EH&S Manager, whose duties will include consulting with the campuses as well as conducting follow up on compliance issues. The finalists were interviewed on October 23, 2018.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #6 To: University, California State

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should incorporate the risks identified in its assessments into the University Auditor's audit plan to ensure that the University Auditor evaluates problem areas related to campus health and safety.

Annual Follow-Up Agency Response From October 2021

In March 2021, Systemwide Risk Management again shared the risks identified by their assessment of the annual reporting data with Audit and Advisory Services (A&AS). A&AS evaluated the data as part of its risk assessment and audit planning process.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2020

As part of the 2019 audit plan, the division of Audit and Advisory Services completed health and safety audits at all 23 campuses and the Chancellor's Office. The audits reviewed areas similar to those reviewed by the State Auditor.

In addition, after analyzing the data from the first round of annual reports, Systemwide Risk Management determined that revisions to the reporting template were needed. The second round of annual reports is due in November 2020, and Systemwide Risk Management will annually share the risks identified by their assessment of the annual reporting data with Audit and Advisory Services for inclusion in their audit planning.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2019

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation. The Chancellor's Office will share the risks identified from the campus reports with Audit and Advisory Services to incorporate identified risks into future audit plans related to health and safety.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation. The division of Audit and Advisory Services began conducting health and safety audits in January 2019. Information from the annual reports will be reviewed and incorporated as appropriate for any campuses that have not yet been audited by that time. In addition, information from the annual reports will be utilized for future audits related to health and safety.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation. The division of Audit and Advisory Services plans to begin conducting health and safety audits at the beginning of 2019. Information from the annual reports will be reviewed and incorporated as appropriate for any campuses that have not yet been audited by that time. In addition, information from the annual reports will be utilized for future audits related to health and safety.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation. The division of Audit and Advisory Services plans to begin conducting health and safety audits at the beginning of 2019. Information from the annual reports will be reviewed and incorporated as appropriate for any campuses that have not yet been audited by that time. In addition, information from the annual reports will be utilized for future audits related to health and safety.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #7 To: University, California State

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should follow up with campuses that fail to submit the required annual health and safety reports and take appropriate steps to ensure compliance with this requirement.

Annual Follow-Up Agency Response From October 2020

The Chancellor's Office ensured that all campuses submitted the required annual health and safety reports.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office developed and distributed a uniform health and safety reporting template to campus environmental health and safety directors. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we can begin implementation of this recommendation. In addition, a new Systemwide Environmental Health and Safety Manager started work at the Chancellor's Office on December 17, 2018; his duties include consulting with the campuses as well as conducting follow up on compliance issues.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation. In addition, the Chancellor's Office is in the final stages of recruiting a Systemwide EH&S Manager, whose duties will include consulting with the campuses as well as conducting follow up on compliance issues. The finalists were interviewed on October 23, 2018.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

This recommendation requires that a new reporting template be in use before we can begin the implementation. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting those reports in September 2019. Once those reports have been received by the Chancellor's Office, we can begin implementation of this recommendation.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #8 To: University, California State

To ensure that it identifies systemwide trends and makes appropriate recommendations to address health and safety issues, the Chancellor's Office should work with the appropriate union to form a systemwide joint committee, as agreed upon in its bargaining agreement with the union, by September 2018.

60-Day Agency Response

The Chancellor's Office has been working with the union and has formed a systemwide joint health and safety committee. The committee held its first meeting on June 7, 2018.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #9 To: University, California State

To ensure that it identifies systemwide trends and makes appropriate recommendations to address health and safety issues, the Chancellor's Office should ensure that the systemwide joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement by actively working with the union on an ongoing basis.

6-Month Agency Response

As reported in our 60-day response, the systemwide joint committee was formed and subsequently held its first meeting on June 7, 2018. The committee held its second meeting on October 4, 2018, and a third meeting is scheduled for January 10, 2019. The committee will continue to meet quarterly.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

The systemwide joint committee was formed and held its first meeting on June 7, 2018. The committee plans to meet approximately every three months. Because half of the 12-member committee consists of union members, conducting regular meetings will ensure that the committee is actively working with the union on an ongoing basis.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #10 To: University, California State

To ensure the health and safety of employees working with hazardous materials, the Chancellor's Office should prescribe the frequency for which the campuses provide refresher laboratory safety training to employees.

Annual Follow-Up Agency Response From October 2021

The issue of refresher training has been successfully bargained and agreed to and the revised policy has been finalized. Employees shall receive refresher laboratory safety training a minimum of every three years.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2020

As reported previously, the Chancellor's Office drafted a new policy to provide a framework for administrative health and safety processes, assessment, and reporting. The draft policy proposes that employees shall receive refresher laboratory safety training a minimum of every three years. Because the proposed policy changes may have an impact on the terms and conditions of employment, and after meeting with the three unions that requested to meet and confer, an updated draft was provided to all employee unions in December 2019 for further review. Only one union (CSUEU) requested to again meet and confer on the revised document but did not provide any dates and has not identified any reasonably foreseeable impact of the revised draft policy. CSU made several attempts to obtain dates from the union. After notifying the union on October 15, 2020 of the CSU's intention to implement the policy on or after November 2, 2020, unless the union articulates reasonably foreseeable impacts and provides prompt dates, the union then indicated its intention to file an unfair labor practice charge with the Public Employment Relations Board for violation of the collective bargaining law (HEERA) if the CSU implements the new policy. The CSU continues to seek dates from the union to complete the meet and confer process.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2019

The Chancellor's Office drafted a new policy to provide a framework for administrative health and safety processes, assessment, and reporting. The draft policy proposes that in addition to initial laboratory safety training, employees shall receive refresher training a minimum of every three years, or more frequently as warranted by changing hazards, regulations, or at a campus's discretion to implement training more frequently than prescribed. Proposed policy changes that may impact the terms and conditions of employment have to be provided to the unions for their review. The Chancellor's Office provided the draft policy to the unions in March 2019 and three unions requested to meet and confer. To date, Systemwide Risk Management has met with all three unions and is in the process of incorporating recommended and agreed to edits to the policy. The meet and confer process takes several months and based on the feedback from the aforementioned meetings, we anticipate closure of the meet and confer process by April 2020.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

The Chancellor's Office drafted a new policy to provide a framework for administrative health and safety processes, assessment, and reporting. The draft policy proposes that in addition to initial laboratory safety training, employees shall receive refresher training a minimum of every three years, or more frequently as warranted by changing hazards, regulations, or at a campus's discretion to implement training more frequently than prescribed. Proposed policy changes that may impact the terms and conditions of employment have to be provided to the unions for their review. The Chancellor's Office provided the draft policy to the unions in March 2019; to date, three unions have requested to meet and confer. The meet and confer process may take several months.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The Chancellor's Office is drafting a new policy to provide a framework for administrative environmental health and safety processes, assessment, and reporting. The draft policy currently proposes that in addition to initial laboratory safety training, employees shall receive refresher training a minimum of every three years, or more frequently as warranted by changing hazards, regulations, or at a campus's discretion to implement training more frequently than prescribed.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The Chancellor's Office is consulting with the campuses to help determine the appropriate frequency for refresher laboratory safety training for employees. In addition, the Chancellor's Office is in the process of deploying a new learning management system for academic year 2018-19 and integrating e-learning content available from the Safety Training Consortium.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #11 To: Channel Islands, California State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Channel Islands should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

6-Month Agency Response

CSU Channel Islands facilitates a monthly safety committee meetings (SCM) for both the State Employee Trade Council (SETC) and California State University Employees Union (CSUEU). The committees have equal membership from each union and management. The intent of these standing committees shall be to review work safety issues and identify ways for improvements. These SCM meetings commenced in April 2018. It should be noted that the intent of this Collective Bargaining Agreement requirement has been met by facilitating a joint meeting with both unions and management, where safety concerns are discussed and addressed.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

CSU Channel Islands facilitates a monthly safety committee meeting (SCM) for both the SETC and CSUEU bargaining units (unions) that will occur on the third Thursday of every month at 9:00 am, and will have equal membership from each union and management (three persons each from both unions as well as campus Facilities Management). The intent of this standing committee shall be to review work safety issues and identify ways for improvements. These SCM meetings commenced in April 2018. It should be noted that the intent of this requirement of the Collective Bargaining Agreement has been met by facilitating a joint meeting with both unions and management, where safety concerns are discussed and addressed. For your review, we have provided the sign-in sheets for the meetings held to date on April 5, 2018, and May 3, 2018.

California State Auditor's Assessment of 60-Day Status: Pending

Channel Islands did not provide the necessary documents at the time of its response to substantiate its claim of full implementation.

Recommendation #12 To: Sacramento, California State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sacramento should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

6-Month Agency Response

Sacramento State has re-formed its campus-level joint health and safety committee under the CSU Collective Bargaining Agreement with Unit 6 (State Employee Trades Council/Teamsters Local 2010). The committee met in September 2018 and will continue to do so on a monthly basis or by mutual agreement, in accordance with the bargaining agreement.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

Sacramento State will ensure that it fulfills its responsibilities regarding a campus-level joint health and safety committee under the CSU Collective Bargaining Agreement with the State Employee Trades Council. The Chancellor's Office recently reestablished the systemwide joint committee and, with that committee now in place for the campus-level committee to report to, we will re-form our campus-level committee.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #13 To: San Diego, California State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, San Diego should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

6-Month Agency Response

The campus has re-structured existing safety committees to bring them in compliance with Teamsters / SETC (Unit 6) Collective Bargaining Agreement. Current members of existing safety committees continue to meet and develop plans while addressing ongoing campus concerns. A new committee, with equal number of members, representing Union (selected by and represented the State Employees Trade Council (SETC)) and Management was established on June 26, 2018 and has been meeting monthly.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

Campus is moving to re-structure existing safety committees to bring them in compliance with Teamsters / SETC (Unit 6) Collective Bargaining Agreement. Current members of existing safety committees continue to meet and develop plans for a compliant committee while addressing ongoing campus concerns. New committee will draft procedures including reports to memorialize a compliant approach and assure continued adherence to Collective Bargaining Agreement.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #14 To: Sonoma State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sonoma should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

60-Day Agency Response

To augment our Safety Committee we formed the SETC/Teamster Safety Committee, a joint committee consisting of equal parts of union and management representatives. The first meeting was held 04/30/2018 and a subsequent meeting held 05/31/2018.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #15 To: Channel Islands, California State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Channel Islands should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

1-Year Agency Response

Channel Islands' joint safety committee meeting minutes are recorded and provided electronically to the systemwide joint committee.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Channel Islands provided evidence demonstrating that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee.

6-Month Agency Response

Minutes are taken jointly by representatives from the participating unions and management, and once approved by all parties, the minutes are distributed to all Facilities Services (FS) staff, and a copy submitted to the systemwide joint safety committees.

California State Auditor's Assessment of 6-Month Status: Pending

Until Channel Islands demonstrates that it has provided copies of the meeting minutes to the systemwide joint committee, we will continue to report this recommendation as not fully implemented.

60-Day Agency Response

CSU Channel Islands' safety committee meeting minutes are recorded. We will provide copies of the meetings minutes for the first two meetings held on April 5, 2018, and May 3, 2018.

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #16 To: Sacramento, California State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sacramento should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

6-Month Agency Response

Sacramento State's campus-level joint health and safety committee, formed under the CSU Collective Bargaining Agreement with Unit 6 (State Employee Trades Council/Teamsters Local 2010), will record meeting minutes and provide copies of the minutes and other information to the systemwide joint committee when requested. Minutes for the committee's September 2018 meeting were recorded and distributed to members. The same will occur for future meetings.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

Sacramento State will ensure that its campus-level joint health and safety committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #17 To: San Diego, California State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, San Diego should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

6-Month Agency Response

The campus joint safety committee now records meeting minutes and provides copies of the minutes to the committee members. The minutes are also maintained with the Joint Safety Committee Secretary in Facilities Services. Minutes are also available to the Systemwide Health and Safety Committee upon request.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

Charge for re-structuring of current safety committee includes drafting procedures including reports to memorialize a compliant approach and assure continued adherence to Collective Bargaining Agreement. Meeting minutes and distribution of minutes will be a central tenant of the new procedures currently under development. Approach will include a process for independent confirmation of minutes distribution.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #18 To: Sonoma State University

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sonoma should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

Annual Follow-Up Agency Response From October 2019

Sonoma State University conducts monthly Safety Committee Meetings with the Teamsters, per the Teamster Local 2010 CBA between the Teamsters and the CSU. Each meeting is formally documented with an agenda and meeting minutes. In order to comply with the information dissemination to the Systemwide Joint Committee, Sonoma State University has created procedures outlining the steps to ensure meeting minutes are sent via email to the systemwide joint committee.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Along with its one year response in April 2019, Sonoma provided evidence demonstrating that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee. Additionally, it has now established a procedure to ensure that its joint committee will consistently forward its meeting minutes to the systemwide joint committee. Sonoma also provided evidence that it continues to forward the meeting minutes.

1-Year Agency Response

Our safety minutes for both our Campus-wide Safety Committee and our Sonoma State University Teamster Corporation Yard Sub-Safety Committee are sent to the Jody Vanleuven, Assistant Director of CSU Risk Management. Jody is responsible for the System-wide Joint Committee.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Sonoma provided evidence demonstrating that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee. However, it has not established a policy or procedure to ensure that its joint committee will consistently forward its meeting minutes to the systemwide joint committee.

6-Month Agency Response

The committee holds monthly meetings to discuss the charge of the committee, meeting schedules, committee organization, and other current topics.

Meeting minutes are posted for public viewing at http://web.sonoma.edu/ehs/safety/committees.html. Meeting minutes from April 2018, May 2018, July 2018, August 2018, and September 2018 will be provided to the CSA.

California State Auditor's Assessment of 6-Month Status: Pending

Sonoma did not provide any documentation to support its claim that it has fully implemented this recommendation.

60-Day Agency Response

The committee held a meeting on 05/31/2018 to discuss the charge of the committee, meeting schedules, committee organization, and other current topics.

Meeting minutes will be provided along with the website that the minutes are posted to for public viewing.

California State Auditor's Assessment of 60-Day Status: Pending

Sonoma did not provide documentation demonstrating that it has implemented this recommendation.

Recommendation #19 To: Sacramento, California State University

To increase its oversight of chemical safety, Sacramento should establish a chemical committee consistent with its chemical plan requirements.

60-Day Agency Response

Sacramento State has established an Executive Safety Committee to serve as the chemical committee required by its chemical plan, among other functions.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #20 To: Sacramento, California State University

To increase its oversight of chemical safety, Sacramento should, by June 2018, specify how often the new chemical committee should meet and then ensure that it meets as frequently as required and that it proactively addresses issues related to chemical hygiene and safety on campus.

60-Day Agency Response

Sacramento State has established an Executive Safety Committee (ESC) to serve as the chemical committee required by its chemical plan, among other functions. The ESC charge specifies that the committee will meet monthly during the academic year. The ESC held meetings for February, March, and April 2018 consistent with the committee charge, and the minutes from these meetings demonstrate that the ESC is proactively addressing issues related to chemical hygiene and safety on campus. The ESC meeting schedule is posted on the campus website. At this time, ESC meetings have been scheduled through February 2019.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #21 To: Sacramento, California State University

To increase its oversight of chemical safety, Sacramento should ensure that the new chemical committee records its meeting minutes and makes those minutes available to all employees.

60-Day Agency Response

Sacramento State has established an Executive Safety Committee (ESC) to serve as the chemical committee required by its chemical plan, among other functions. The ESC records its meeting minutes and posts them online, where they are available to all employees.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #22 To: Sonoma State University

To increase oversight of chemical safety, Sonoma should, by June 2018, specify in its chemical plan how often its chemical committee should meet.

60-Day Agency Response

The Chemical Hygiene Committee that previously met on an annual basis, will now meet in person near the end of each semester, with day-to-day business handled electronically via email. Additional meetings to be held upon the request of any committee member.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #23 To: Sonoma State University

To increase oversight of chemical safety, Sonoma should ensure that its chemical committee meets as frequently as required and that it proactively addresses issues related to chemical hygiene and safety on campus.

Annual Follow-Up Agency Response From October 2019

Sonoma State University's Chemical Hygiene Committee meets twice a year at a minimum or more often as needed. The committee is composed of representatives from Science, Biology, Chemistry, Art, and Environmental Health and Safety. The committee's discussions are included in the meeting minutes, which are posted on the university's website.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Along with its one year response in April 2019, Sonoma provided evidence demonstrating that its chemical committee met in late-2018. The campus has now provided evidence that its chemical committee held a meeting in the Spring and Fall 2019 semesters.

1-Year Agency Response

Considered fully implemented by campus at 60 day response.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Sonoma provided evidence demonstrating that its chemical committee met in late-2018. The campus provided no evidence that its chemical committee held a meeting in the Spring 2019 semester.

6-Month Agency Response

The Chemical Hygiene Committee met on 03/29/2018 to discuss safety inspections, the Chemical Hygiene Plan, and other related topics. We record and post meeting minutes to our website, http://web.sonoma.edu/ehs/safety/committees.html.

The Chemical Hygiene Plan indicates the Chemical Hygiene Committee will meet once a semester. The committee meeting for the Fall 2018 semester is scheduled for November 2018.

California State Auditor's Assessment of 6-Month Status: Pending

Sonoma did not provide any documentation to support its claim that it has fully implemented this recommendation.

60-Day Agency Response

The Chemical Hygiene Committee met 03/29/2018 to discuss safety inspections, the Chemical Hygiene Plan, and other related topics. We record and post meeting minutes to our website, http://web.sonoma.edu/ehs/safety/committees.html

California State Auditor's Assessment of 60-Day Status: Pending

Although the campus provided evidence that the Chemical Hygiene Committee met in March, Sonoma needs to demonstrate that the committee meets every six months as required in its chemical hygiene plan. As such, we will assess the campus's implementation of this recommendation in its subsequent responses to this recommendation.

Recommendation #24 To: Sonoma State University

To increase oversight of chemical safety, Sonoma should ensure that its chemical committee records its meeting minutes and makes those minutes available to all employees.

60-Day Agency Response

The university records Chemical Hygiene Committee meeting minutes and posts them to our website, http://web.sonoma.edu/ehs/safety/committees.html

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #25 To: Channel Islands, California State University

To more effectively provide oversight of its chemical plan, Channel Islands should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

60-Day Agency Response

The Channel Islands EH&S unit conducts annual reviews of the Chemical Hygiene Plan(CHP) to certify that the document continues to provide effective safety guidelines and reflects best practices. The annual review meetings include EH&S staff, as well as Departmental chemical hygiene officers/safety coordinators. Each person must provide their signature and date confirming they have reviewed the CHP. The evaluation is intended to provide a

comprehensive assessment of effectiveness. Revisions to the Chemical Hygiene Plan will reflect best practices and aim to safeguard the health and welfare of students, faculty, and staff.

Recommended revisions, alterations, amendments, or modifications to the CHP will be discussed, evaluated and documented. EH&S will annotate recommendations and implement appropriate changes to the CHP.

The initial documented review took place on May 10, 2018. We have provided documentation related to the May 2018 CHP Annual Effectiveness Review's scheduling and participants, as well as the May 2018 Chemical Hygiene Annual Evaluation and Effectiveness

Review document, signed by the participants.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #26 To: Sacramento, California State University

To more effectively provide oversight of its chemical plan, Sacramento should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

6-Month Agency Response

Sacramento State's Environmental Health and Safety office completed and documented an evaluation of the campus's chemical plan. The results of the evaluation (including recommended revisions) were provided to the campus's Executive Safety Committee (ESC) and discussed and accepted at the ESC's September 2018 meeting, as reflected in the meeting minutes. The campus will repeat this process on an annual basis.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

Sacramento State will annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions. Completed evaluations will be reviewed by the campus's Executive Safety Committee (ESC). The campus Environmental Health and Safety office is in the process of creating a plan for annually evaluating the chemical plan and of conducting an annual review of the chemical plan for 2018. The campus Environmental Health and Safety office will report on the 2018 review to the ESC in September and annually thereafter.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #27 To: San Diego, California State University

To more effectively provide oversight of its chemical plan, San Diego should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

1-Year Agency Response

SDSU has developed a plan that annually evaluates its chemical hygiene plan and documents the results.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

San Diego provided evidence demonstrating that it evaluated its chemical hygiene plan, documented the results of its evaluations, and plans to continue those evaluations annually. To the extent that San Diego continues this practice, it has fully addressed our recommendation.

6-Month Agency Response

The Chemical Hygiene Officer (CHO) reviewed SDSU's Chemical Hygiene Plan (CHP) for effectiveness and documented its evaluation in June 2018. The evaluation summarized the improvements made which included identifying the individual responsible for the annual review of the plan, revised roles and responsibilities of parties, and clearly identified those responsible for providing lab specific safety training and documentation of the training records. This process will continue to be performed annually.

California State Auditor's Assessment of 6-Month Status: Pending

San Diego did not provide evidence of the annual evaluation it claims it performed in June 2018.

60-Day Agency Response

Chemical Hygiene Officer (CHO) reviewed the 2017 SDSU Chemical Hygiene Plan (CHP) for effectiveness and documented its evaluation. The evaluation summarizes the improvements made to the 2018 SDSU Chemical Hygiene Plan. We will continue to perform annually the evaluation of the chemical plan.

California State Auditor's Assessment of 60-Day Status: Pending

San Diego did not provide documentation to support its evaluation of the Chemical Hygiene Plan. Until it does so, we will report the status of this recommendation as pending.

Recommendation #28 To: Sonoma State University

To more effectively provide oversight of its chemical plan, Sonoma should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

1-Year Agency Response

As a result of the audit, all safety programs to include the Chemical Hygiene Plan are reviewed and evaluated for effectiveness annually. The review and any changes are tracked in a Record of Revision. This assists anyone reading the plan in understanding what changes were made and the reasoning.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Sonoma provided evidence demonstrating that it evaluated its chemical plan in February 2019 for effectiveness and documented the results of that evaluation, including its discussions of any recommended revisions. It also stated within its chemical plan that it will review and update the plan annually.

6-Month Agency Response

The Chemical Hygiene Committee reviewed the Chemical Hygiene Plan at the 03/29/2018 meeting. The campus posted Revision 3.1 of the Chemical Hygiene Plan to our website in May 2018. The campus has revised the minutes of the 03/29/2018 meeting to more accurately reflect the discussion and evaluation of the Chemical Hygiene Plan at that time.

California State Auditor's Assessment of 6-Month Status: Pending

Sonoma did not provide any documentation to support its claim that it has fully implemented this recommendation.

60-Day Agency Response

The Chemical Hygiene Committee reviewed the Chemical Hygiene Plan at the 03/29/2018 meeting. The university posted Revision 3.1 of the Chemical Hygiene Plan to our website in May 2018. The Chemical Hygiene Plan will be reviewed annually by the committee and can be found on our website, http://web.sonoma.edu/ehs/hygiene/

California State Auditor's Assessment of 60-Day Status: Pending

As we stated on page 22 of our report, state regulations require campuses to review and evaluate the effectiveness of their chemical plans at least annually and to update them as needed. The Chemical Hygiene Committee's meeting minutes that Sonoma provided show that the committee directed some changes, including changes to laboratory safety inspection forms and storage of inspection records. However, it is unclear whether the campus performed a comprehensive evaluation of its chemical hygiene plan as required. Until it is able to demonstrate that it has conducted this evaluation, we will continue to report this recommendation as pending.

Recommendation #29 To: Sacramento, California State University

To ensure that it has a chemical plan that is up to date and reflects current campus practices, Sacramento should develop and implement a revised chemical plan by January 2019.

1-Year Agency Response

Sacramento State has developed and implemented a revised chemical plan.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

Sacramento State completed an annual evaluation of its chemical plan in September 2018. Revisions will be made to the chemical plan based on the results of the evaluation and implemented by January 2019.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Sacramento State will complete an annual evaluation of its chemical plan in September 2018. Revisions will be made to the chemical plan based on the results of the evaluation and implemented by January 2019.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #30 To: San Diego, California State University

San Diego should ensure that its chemical plan clearly defines the campus entity or individual who is responsible for reviewing and evaluating the effectiveness of its chemical plan at least annually.

60-Day Agency Response

The 2018 SDSU Chemical Hygiene Plan (CHP) has been revised to clearly indicate that the Chemical Hygiene Officer (CHO) is responsible for annually reviewing and evaluating the effectiveness of the CHP.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #31 To: Sonoma State University

To ensure that its chemical plan is updated to reflect current practices and changes to how the campus may have evolved, Sonoma should immediately update its chemical plan.

1-Year Agency Response

As a result of the audit, all safety programs to include the Chemical Hygiene Plan are reviewed and evaluated for effectiveness annually.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Sonoma provided evidence demonstrating that it updated its chemical plan.

6-Month Agency Response

The Chemical Hygiene Plan was updated in May 2018. The Chemical Hygiene Plan can be found on the university's website, http://web.sonoma.edu/ehs/hygiene/

California State Auditor's Assessment of 6-Month Status: Pending

As described in Recommendation 28, Sonoma provided no evidence that it evaluated its chemical plan before updating it.

60-Day Agency Response

The Chemical Hygiene Plan was updated in May 2018. The Chemical Hygiene Plan can be found on the university's website, http://web.sonoma.edu/ehs/hygiene/

California State Auditor's Assessment of 60-Day Status: Pending

Sonoma did not provide any documentation to support its claim that it has fully implemented this recommendation.

Recommendation #32 To: Channel Islands, California State University

To ensure the health and safety of employees working with hazardous materials, Channel Islands should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

60-Day Agency Response

Channel Islands, utilizing State regulations, has identified the trainings required for each job classification and developed a Training Recommendation Plan which identifies those employees in positions that are required to take training related to laboratory safety, hazardous waste, hazard communication, and bloodborne pathogens. It is our intent to make available and require training regardless of when their most recent training occurred. We have provided for your review, our current lists of those who fall within the identified classifications.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #33 To: Sacramento, California State University

To ensure the health and safety of employees working with hazardous materials, Sacramento should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

60-Day Agency Response

Sacramento State has reviewed the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, and bloodborne pathogens; identified those who have not taken these trainings; and shared this information with the relevant departments.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #34 To: San Diego, California State University

To ensure the health and safety of employees working with hazardous materials, San Diego should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

1-Year Agency Response

SDSU has reviewed all the training records for employees working with hazardous materials. As of March 2019, only two employees have not completed the required hazardous materials training. Training for these employees will be completed by October 2019.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

The campus completed its review of training records of all employees who are required to take training. We identified thirty two (32) individuals who had not completed the required training. The employees have been notified and instructed to complete the required training by March 2019.

California State Auditor's Assessment of 6-Month Status: Pending

Until San Diego provides evidence that all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens, we will continue to report this recommendation as not fully implemented.

60-Day Agency Response

The campus is currently reviewing training records of all impacted employees. We anticipate full implementation by July 2018.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #35 To: Sonoma State University

To ensure the health and safety of employees working with hazardous materials, Sonoma should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

1-Year Agency Response

In response to the audit recommendation, SSU has assembled a training matrix outlining the type of safety training an employee needs to complete based on the job classification and potential hazards/exposures.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Sonoma provided evidence demonstrating that it identified the employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identified those who have not taken these trainings.

6-Month Agency Response

The university has reviewed our training records of all employees who are required to take training related to laboratory safety, hazardous waste, hazard communication, or blood borne pathogens and identified all employees required to take the training.

California State Auditor's Assessment of 6-Month Status: Pending

Sonoma did not provide any documentation to support its claim that it has fully implemented this recommendation.

60-Day Agency Response

The university has reviewed our training records of all employees who are required to take training related to laboratory safety, hazardous waste, hazard communication, or blood borne pathogens and identified all employees required to take the training.

California State Auditor's Assessment of 60-Day Status: Pending

Until Sonoma provides evidence demonstrating that all employees required to take the specified trainings have done so, we will continue to report this recommendation as not fully implemented.

Recommendation #36 To: Channel Islands, California State University

To ensure the health and safety of employees working with hazardous materials, Channel Islands should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

1-Year Agency Response

All required trainings, except the CSU Chemical Hygiene training module, are available through the online campus training portal. Formal announcements about training requirements and training availability were sent by email on August 23rd and October 19th to all affected faculty and staff, and presented to appropriate departmental chairs during meetings on September 5th and September 13th, 2018. Additionally, the Environmental Health and Safety (EHS) department has provided in-person Chemical Hygiene trainings for the appropriate faculty and staff; six in fall 2018, and 21 additional sessions between January and April 2019.

Finally, both Academic Affairs and Facilities Services have finalized procedures to ensure that the employees have received all required trainings for their respective areas.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Channel Islands provided evidence demonstrating that it made the required trainings available to employees and established procedures for ensuring that the employees have received all required trainings.

6-Month Agency Response

All required trainings, except the CSU Chemical Hygiene training module, are currently available through the online campus training portal. Formal announcements about training requirements and training availability were presented to appropriate department chairs during meetings on September 5th and September 13th, 2018. The campus Environment, Health and Safety (EHS) unit has scheduled multiple dates to offer the Chemical Hygiene training to the appropriate faculty and staff before December 2018. In addition, both Academic Affairs and Facilities Services have developed draft procedures to enforce the training requirements for their respective areas, which are being reviewed with the appropriate unions. We expect the procedures will be finalized by December 2018.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

By December 2018, Channel Islands will ensure that all required training will be made available to those employees that require training. In addition, procedures will be developed to ensure employees complete necessary trainings. The two units with employees requiring these trainings, Academic Affairs and Facilities Services, have identified all employees currently falling into the categories identified.

With changes to faculty/courses, it is anticipated that some faculty will be added or removed later in the summer.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #37 To: Sacramento, California State University

To ensure the health and safety of employees working with hazardous materials, Sacramento should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

1-Year Agency Response

Sacramento State continues to make laboratory safety, hazardous waste, hazard communication, and bloodborne pathogen training available to employees through online and live trainings and has established procedures for ensuring that employees receive all required trainings. The campus also continues to work on implementing a new learning management system that should facilitate this effort once in place.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Sacramento provided evidence that it has made the required trainings available to employees and has established procedures for ensuring that the employees have received all required trainings.

6-Month Agency Response

Sacramento State continues to make laboratory safety, hazardous waste, hazard communication, and bloodborne pathogen training available to employees through online and live trainings. The campus Environmental Health and Safety office is working with relevant departments to ensure they understand their obligations with respect to employee safety training and to establish procedures for ensuring that employees have received all required trainings. The campus also continues to work with a new learning management system provider to develop a system to facilitate monitoring of employee training status.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Sacramento State makes laboratory safety, hazardous waste, hazard communication, and bloodborne pathogen training available to employees through online and live trainings. When faculty return to campus for the Fall 2018 semester, Sacramento State will follow up with the relevant departments to ensure employees have received all the trainings they require for working with hazardous materials. Additionally, the campus is currently working with a new learning management system provider to develop a system to facilitate monitoring of employee training status.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #38 To: San Diego, California State University

To ensure the health and safety of employees working with hazardous materials, San Diego should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

Annual Follow-Up Agency Response From November 2020

San Diego State University has reviewed its training records and developed procedures for assigning and monitoring in-person or on-line safety training for new and current employees. The campus is utilizing the features of the CSU Learn (SumTotal) Learning Management System (LMS) to ensure employees receive the required training and that it is appropriately tracked by the campus.

CSU Learn sends automated emails at regular intervals (generally weekly) to the employee and their supervisor when training has not been completed by the specified due date. EH&S generates monthly reports to identify employees that have not completed training.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

San Diego provided evidence demonstrating that it made the required trainings available to employees and established a training program and procedures related to the trainings and their frequency. In addition, the procedures describe how it will ensure that the employees have received all required trainings.

Annual Follow-Up Agency Response From October 2019

The recommendation has been fully implemented. Procedures have been strengthened to ensure employees receive all required training either in-person or on-line. The procedures describe how new and current employees are assigned to safety training and the notification process. The campus is now utilizing the many features of the CSU Learn (SumTotal) learning management system (LMS) to ensure employees receive the required training and that it is appropriately tracked by the campus. When employees are identified for training by academic and non-academic departments, that information is entered into the LMS. The system provides biweekly employee status monitoring to Environmental Health and Safety Department (EHS) and reminder notifications to employees. On a monthly basis, EHS informs department management of training deficiencies identified by CSU Learn for follow-up resolution.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

San Diego provided evidence demonstrating that it made the required trainings available to employees and established procedures related to the trainings and their frequency. However, the procedures do not describe how it will ensure that the employees have received all required trainings.

1-Year Agency Response

The campus has developed an employee health and safety training management procedures document. It lists training courses by work area. In addition, EHS has an updated roster that includes training completion dates for those employees with health and safety training requirements. At the systemwide level, the Chancellor's Office is implementing a learning management system, "Sum Total". This system will replace the current manual tracking with a modern automated tool.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

San Diego provided evidence demonstrating that it made the required trainings available to employees and established procedures related to the trainings and their frequency. However, the procedures do not describe how it will ensure that the employees have received all required trainings. Therefore, we have assessed this recommendation as partially implemented.

6-Month Agency Response

Implementation is in progress. The campus has identified employees who are required to take training as noted in Recommendation 34. Training for these individuals will commence after "Sum Total", a new CSU systemwide learning management system, is implemented by the Chancellor's Office.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Implementation is in progress. The campus is currently reviewing training records of all impacted employees. Training will be made available and procedures will be established to ensure that training is completed.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #39 To: Sonoma State University

To ensure the health and safety of employees working with hazardous materials, Sonoma should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

Annual Follow-Up Agency Response From October 2019

Sonoma State University has reviewed our training records and identified all employees required to take the training related to laboratory safety, hazardous waste, hazard communication, or blood borne pathogens. We've made trainings available to employees and developed procedures for assigning and monitoring required trainings.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

At its one year response in April 2019, Sonoma provided evidence demonstrating that it made the required trainings available to employees. In October 2019, it also provided evidence that it established procedures for ensuring that the employees have received all required trainings.

1-Year Agency Response

In response to the audit recommendation, SSU has assembled a training matrix outlining the type of safety training an employee needs to complete based on the job classification and potential hazards/exposures.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Although Sonoma provided evidence demonstrating that it made the required trainings available to employees, it did not provide any evidence that it established procedures for ensuring that the employees have received all required trainings.

6-Month Agency Response

The university has reviewed our training records and identified all employees required to take the training related to laboratory safety, hazardous waste, hazard communication, or blood borne pathogens. The campus is currently working on implementing a learning management software solution to coordinate, schdule, and monitor required trainings.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The university has reviewed our training records and identified all employees required to take the training related to laboratory safety, hazardous waste, hazard communication, or blood borne pathogens. We will provide the required training by December 2018 as recommended.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #40 To: Channel Islands, California State University

To ensure the health and safety of employees working with hazardous materials, Channel Islands should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

1-Year Agency Response

Channel Islands has developed and implemented procedures to ensure all employees receive training, as required. Monitoring provisions are noted in the Academic Affairs and Facilities Services updated procedures. As noted in these procedures, compliance monitoring responsibilities are shared between the Safety Training Coordinators and the Environmental Health and Safety (EHS) department, and training records are maintained through an electronic training compliance recordkeeping system.

In addition, trainings are available to equip individuals responsible for monitoring training records with the awareness of how to take full advantage of the electronic training portal's recordkeeping capabilities.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Channel Islands provided evidence that demonstrates that it regularly monitors employee training records to ensure that all employees have received the required trainings.

6-Month Agency Response

Channel Islands has developed and implemented procedures to provide employees with required trainings. Monitoring provisions are noted in the Academic Affairs and Facilities Services enforcement procedures. In addition, the Chancellor's Office is conducting trainings to equip individuals responsible for monitoring training records with the awareness of how to take full advantage of the CSU's electronic training portal's recordkeeping capabilities.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Channel Islands will conduct ongoing monitoring of employee training records to ensure that all employees receive training, as required.

Further development of the training/refresher training plan is underway and/or scheduled.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #41 To: Sacramento, California State University

To ensure the health and safety of employees working with hazardous materials, Sacramento should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

1-Year Agency Response

Sacramento State has implemented a process to regularly monitor employee training records and follow up with relevant departments to ensure employees receive required trainings. The campus continues to work with a new learning management system provider to develop a system that will automate much of the employee training monitoring process in the future.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Sacramento provided evidence demonstrating that it regularly monitors employee training records to ensure that all employees have received the required trainings.

6-Month Agency Response

Sacramento State will, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings. The campus continues to work with a new learning management system provider to develop a system to facilitate monitoring of employee training status.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Sacramento State will, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings. The campus is currently working with a new learning management system provider to develop a system that will facilitate this.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #42 To: San Diego, California State University

To ensure the health and safety of employees working with hazardous materials, San Diego should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

Annual Follow-Up Agency Response From November 2020

San Diego State University has developed and implemented a process to ensure all employees receive training. EH&S has revised its process to regularly monitor employee training records and follow up with relevant departments to ensure employees receive required trainings. The procedures include annual monitoring of required employee safety training to ensure completion. In addition, the University continues to utilize the CSU Learn LMS which will automate the employee training monitoring process.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

San Diego provided evidence demonstrating that it established procedures for how it would monitor the completion of trainings to ensure that all employees have received the required trainings. In addition, the procedures indicate how, and how regularly, it tracks and monitors employee training records for all required trainings.

Annual Follow-Up Agency Response From October 2019

The recommendation has been fully implemented. Procedures have been strengthened to ensure employees receive all required training either in-person or on-line. The procedures describe how new and current employees are assigned to safety training and the notification process. The campus is now utilizing the many features of the CSU Learn (SumTotal) learning management system (LMS) to ensure employees receive the required training and that it is appropriately tracked by the campus. When employees are identified for training by academic and non-academic departments, that information is entered into the LMS. The system provides biweekly employee status monitoring to Environmental Health and Safety Department (EHS) and reminder notifications to employees and supervisors. On a monthly basis, EHS informs department management of training deficiencies identified by CSU Learn for follow-up resolution.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

San Diego provided evidence demonstrating that it established procedures indicating that it would monitor the completion of trainings and that it monitors some employee training records to ensure that all employees have received the required trainings. However, the procedures it established do not indicate how, or how regularly, it tracks and monitors employee training records for all required trainings. Until it does so, we will continue to assess this as partially implemented.

1-Year Agency Response

The procedures document identified in Recommendation 38 is used to regularly monitor employee training records. Monthly, SDSU's Center for Human Resources provides EHS with a roster of employees who attended New Employee Orientation training. EHS reviews the list and identifies those employees who require hazardous materials training. They are contacted and scheduled to attend training, which is provided monthly. As referenced in Recommendation 38, at the systemwide level, the Chancellor's Office is implementing a learning management system, "Sum Total", which will track and administer health and safety training requirements for employees. This will improve the current manual tracking with a modern automated tool.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

San Diego provided evidence demonstrating that it established procedures indicating that it would monitor the completion of trainings and that it monitors some employee training records to ensure that all employees have received the required trainings. However, the procedures it established do not indicate how, or how regularly, it tracks and monitors employee training records for all required trainings. Until it does so, we will continue to assess this as partially implemented.

6-Month Agency Response

Implementation is in progress. Once training has been completed for those employees required to take and complete training by March 2019, the campus will then regularly monitor training records. To ensure compliance, procedures will be developed utilizing "Sum Total", the CSU systemwide learning management system.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Implementation is in progress. The campus is developing procedures to regularly monitor training records to ensure that employees have received required trainings.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #43 To: Sonoma State University

To ensure the health and safety of employees working with hazardous materials, Sonoma should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

Annual Follow-Up Agency Response From October 2019

Sonoma State University developed procedures for assigning and monitoring required safety trainings. The procedures include annual monitoring of required employee safety training to ensure completion. This monitoring was administered in Fall 2019 and as outlined in the procedures, any employee who had not completed the training was contacted along with their supervisor.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Sonoma provided evidence demonstrating that it regularly monitors employee training records to ensure that all employees receive the required trainings. It also implemented procedures for monitoring employee training records.

1-Year Agency Response

The university has a process to regularly monitor records to ensure that all employees have received the required training.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Although Sonoma provided evidence demonstrating that it monitored employee training records in 2018 to ensure that all employees had received the required trainings at that point in time, it did not provide evidence demonstrating that it consistently monitors employee training records on a regular basis.

6-Month Agency Response

The university is working on a process to regularly monitor records to ensure that all employees have received the required training. We aim to implement a learning management software solution to coordinate, schdule, and monitor required trainings by 12/31/2018.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The university is currently working on a process to regularly monitor records to ensure that all employees have received the required training.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #44 To: Channel Islands, California State University

To ensure that employees working in a laboratory setting receive current information regarding laboratory safety, Channel Islands should provide periodic refresher laboratory safety training to these employees beginning in the Fall 2018 semester.

6-Month Agency Response

Channel Islands has implemented its refresher laboratory safety training for employees. Refresher training for hazardous waste and bloodborne pathogens is required annually, and refresher training for Laboratory Safety Fundamentals is required every three years. The trainings are available to all employees online.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

Refresher training will be provided to employees beginning in Fall 2018.

Further development of the training/refresher training plan is scheduled with relevant Academic Affairs Department Chairs, Internal Audit, and campus EH&S once faculty returns in August 2018.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #45 To: Sacramento, California State University

To ensure the health and safety of students in a laboratory setting, Sacramento should, by June 2018, develop campuswide policies to ensure that its departments are accountable for providing student training on laboratory safety.

60-Day Agency Response

Sacramento State developed and implemented a campuswide Student Safety Training (Interim) policy to ensure that its departments are accountable for providing student training on laboratory safety. This policy will remain in place until the adoption of a permanent policy to be approved by the Faculty Senate and other stakeholders during the 2018-2019 academic year.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #46 To: Channel Islands, California State University

To ensure the health and safety of students in a laboratory setting, Channel Islands should work with appropriate faculty to develop student safety training acknowledgement forms by June 2018.

6-Month Agency Response

The campus has developed a standardized student laboratory form (Lab Safety Rules Documentation Form), as well as a process for completion of the forms. The form includes a comprehensive list of general safety guidelines that are applicable to all academic departments involved in laboratory activities. The form can be used in tandem with program-specific forms currently utilized.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

Channel Islands has developed a standardized student laboratory form (Lab Safety Rules Documentation Form). The form is a comprehensive list of general safety guidelines that are applicable to all academic departments involved in laboratory activities. The form can be used in tandem to program-specific forms currently utilized. In addition, Channel Islands has implemented a process by which these forms should be used.

California State Auditor's Assessment of 60-Day Status: Pending

Channel Islands did not provide any documentation to support its claims of full implementation.

Recommendation #47 To: Sacramento, California State University

To ensure the health and safety of students in a laboratory setting, Sacramento should work with appropriate faculty to develop student safety training acknowledgement forms by June 2018.

1-Year Agency Response

Sacramento State has worked with appropriate faculty to develop student safety training acknowledgment forms.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

Since May 2018, Sacramento State's Student Safety Training (Interim) policy has required signed student safety training acknowledgment forms to be obtained for all classes requiring personal protective equipment (PPE). At the start of the Fall 2018 semester, the campus rolled out an electronic student safety training acknowledgement form that is available to all classes requiring PPE. Faculty who teach these classes must use the electronic form or a similar paper form to comply with the policy requirement to document student acknowledgment of safety training. The campus continues to work with appropriate faculty to ensure they have student safety training acknowledgement forms suited to their needs.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Sacramento State is working with appropriate faculty to document student acknowledgment of safety training for classes requiring personal protective equipment (PPE). The campus developed and implemented a campuswide Student Safety Training (Interim) policy that requires departments to have students required to wear PPE sign student safety training acknowledgment forms to demonstrate that they have received proper laboratory safety training. The College of Natural Sciences and Mathematics, where the majority of classes requiring PPE reside, has developed a standard student safety training acknowledgment form that is being used for the Summer 2018 term and beyond. Classes outside of the College of Natural Sciences and Mathematics that require PPE will use an electronic student safety training acknowledgment form that is currently in development and expected to be implemented for the Fall 2018 semester. Until the new electronic form is rolled out, these classes' instructors remain responsible for complying with the policy requirement to document student acknowledgment of safety training.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #48 To: Sonoma State University

To ensure the health and safety of students in a laboratory setting, Sonoma should work with appropriate faculty to develop student safety training acknowledgement forms by June 2018.

6-Month Agency Response

The Chemical Hygiene Committee discussed student safety training acknowledgement forms at their 03/29/2018 meeting. Faculty are included in the membership of the Chemical Hygiene Committee. Student safety training acknowledgement forms are now available for use.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

The Chemical Hygiene Committee discussed student safety training acknowledgement forms at their 03/29/2018 meeting. Faculty are included in the membership of the Chemical Hygiene Committee. Student safety training acknowledgement forms are now available for use.

California State Auditor's Assessment of 60-Day Status: Pending

Sonoma did not provide documentation demonstrating its claim that it has fully implemented the recommendation.

Recommendation #49 To: Channel Islands, California State University

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Channel Islands should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

6-Month Agency Response

Channel Islands has updated and implemented its requirement that all students taking courses where PPE is used complete and sign the campus Lab Safety Rules Documentation form. In addition, the campus has developed companion forms to enhance awareness among students taking classes with more specific potential hazards, including those related to field work.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

60-Day Agency Response

We consider this recommendation to be partially completed.

Channel Islands has developed a standardized student laboratory form (Lab Safety Rules Documentation Form). The form is a comprehensive list of general safety guidelines that are applicable to all academic departments involved in laboratory activities. The form can be used in tandem to program-specific forms currently utilized. In addition, Channel Islands has implemented a process by which these forms should be used.

The campus will begin requiring completion of the Lab Safety Rules Documentation Form for all students needing PPE beginning Summer 2018. The standardized form (noted above) will be piloted this summer prior to general implementation in Fall 2018.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #50 To: Sacramento, California State University

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sacramento should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

1-Year Agency Response

Sacramento State has developed and implemented a campuswide Student Safety Training policy that requires departments to have students required to wear PPE sign student safety training acknowledgment forms to demonstrate that they have received proper laboratory safety training.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

Sacramento State developed and implemented a campuswide Student Safety Training (Interim) policy that requires departments to have students required to wear PPE sign student safety training acknowledgment forms to demonstrate that they have received proper laboratory safety training. The campus continues to work with appropriate faculty to ensure they have student safety training acknowledgement forms suited to their needs.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Sacramento State developed and implemented a campuswide Student Safety Training (Interim) policy that requires departments to have students required to wear PPE sign student safety training acknowledgment forms to demonstrate that they have received proper laboratory safety training. This policy will remain in place until the adoption of a permanent policy to be approved by the Faculty Senate and other stakeholders during the 2018-2019 academic year.

California State Auditor's Assessment of 60-Day Status: Pending

Although Sacramento has issued a policy requiring departments to have students sign student safety training acknowledgment forms, as it noted in response to Recommendation 47, it has not yet developed the student safety training acknowledgment form. We will re-assess Sacramento's response to this recommendation after it has developed the student safety form.

Recommendation #51 To: San Diego, California State University

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, San Diego should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

1-Year Agency Response

In adherence to CSU Executive Order 1039, SDSU requires departments to have students required to wear personal protective equipment sign safety training acknowledgement forms.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

San Diego provided evidence demonstrating that it requires departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

6-Month Agency Response

At the beginning of the Fall 2018 semester, the Associate Deans of the respective colleges were notified regarding proper laboratory safety training. They were asked to identify courses that use hazardous materials and disseminate the acknowledgement forms to those classes for student signatures. They were also reminded that the retention period for these forms is three years after the end of classes.

California State Auditor's Assessment of 6-Month Status: Pending

San Diego did not provide evidence that it requires departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

60-Day Agency Response

Implementation is in progress. The Fall semester begins August 22, 2018 and the campus will begin communicating with the respective departments regarding proper laboratory safety training and to require signed acknowledgement forms from students.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #52 To: Sonoma State University

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sonoma should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

Annual Follow-Up Agency Response From October 2020

Departments provide safety training to students and require students who must wear personal protective equipment to sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training. This requirement has been communicated to the School Deans and Administrative Managers by the Interim Provost and Executive Vice President for Academic Affairs.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Sonoma provided evidence demonstrating that it requires departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

Annual Follow-Up Agency Response From October 2019

Departments have improved their implementation of this recommendation and consistently required students who must wear personal protective equipment to sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Although Sonoma provided evidence demonstrating that students required to wear PPE signed the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training, it did not provide a policy that it requires all departments to have those students sign forms consistently to demonstrate that they have received proper laboratory safety training.

1-Year Agency Response

SSU has developed and implemented student safety in laboratory curriculum.

California State Auditor's Assessment of 1-Year Status: Pending

Although Sonoma provided evidence demonstrating that some students required to wear PPE signed the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training, it did not provide evidence demonstrating that it requires departments to have those students sign forms consistently to demonstrate that they have received proper laboratory safety training.

6-Month Agency Response

The university now requires departments that have students required to wear personal protective equipment to sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training as described in the Chemical Hygiene Plan.

California State Auditor's Assessment of 6-Month Status: Pending

Sonoma did not provide any documentation to support its claim that it has fully implemented this recommendation.

60-Day Agency Response

The university will require departments that have students required to wear personal protective equipment to sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training in August 2018 as recommended.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #53 To: Sacramento, California State University

To ensure the health and safety of students in a laboratory setting, by May 2018, Sacramento should remind all departments to retain student training acknowledgment forms for at least three years after the end of classes.

60-Day Agency Response

Sacramento State has reminded all departments to retain student safety training acknowledgement forms for at least three years after the end of classes.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

Recommendation #54 To: San Diego, California State University

To ensure the health and safety of students in a laboratory setting, by May 2018, San Diego should remind all departments to retain student training acknowledgment forms for at least three years after the end of classes.

1-Year Agency Response

In adherence to CSU Executive Order 1039, campus colleges and departments were reminded that student training acknowledgement forms should be kept on file for at least three years.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

San Diego provided evidence demonstrating that it reminded all departments to retain student training acknowledgment forms for at least three years after the end of classes.

6-Month Agency Response

An email was distributed by the Associate Director, Environmental Health and Safety, to the Associate Deans which reminded the colleges and departments to retain student training acknowledgement forms for at least three years after the end of classes. A sample acknowledgement form was also attached.

California State Auditor's Assessment of 6-Month Status: Pending

Until San Diego can sufficiently demonstrate that it requires departments to have those students required to wear PPE sign the student safety training acknowledgement forms, we will continue to report this recommendation as not fully implemented.

60-Day Agency Response

Implementation is in progress. Departmental communication will be distributed reminding all departments to retain student training acknowledgement forms for at least three years after the end of classes.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #55 To: Sacramento, California State University

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sacramento should perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

1-Year Agency Response

Sacramento State has completed a review to ensure departments are using student safety training acknowledgment forms and are complying with the retention requirement for the forms. The campus has developed procedures for a similar review to be carried out on an annual basis.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Sacramento provided evidence that it performed a review in February 2019 to ensure that all departments are using the student safety training acknowledgement forms and are complying with the retention requirement. It also implemented a policy to ensure that this review process is conducted annually. To the extent that it follows this policy, Sacramento State has fully addressed this recommendation.

6-Month Agency Response

Sacramento State has initiated a review to ensure that all relevant departments are using student safety training acknowledgment forms and are complying with the retention requirement for the forms. Following the completion of this review, the campus will carry out a similar process on an annual basis.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Beginning for the Fall 2018 semester, Sacramento State will perform reviews at least annually to ensure that all departments are using student safety training acknowledgment forms and are complying with the retention requirement.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #56 To: San Diego, California State University

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, San Diego should perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

Annual Follow-Up Agency Response From October 2021

San Diego State University (SDSU) has updated its process for ensuring that departments are providing safety training to students and retaining student acknowledgements. Environmental Health and Safety (EHS) has developed a safety training module in Canvas, our course management system, which faculty can import into their course and consists of a video and short survey that includes the student acknowledgement. Faculty are also able to develop a customized safety training module and include the student acknowledgement in a quiz or survey. When students complete the safety training module, their survey or quiz is retained in the Canvas course record.

Every semester, EHS selects a sample of courses to audit for compliance with student training and works with Instructional Technology Services to get access to the selected courses in Canvas. EHS reviews the course to ensure a safety module was incorporated into the course and to assess the number of students that completed the survey at the end of the module, which includes the student acknowledgement. As the safety training is completed in Canvas, the information is retained indefinitely with the course record. Additionally, EHS continually reviews course offerings to ensure new or removed courses are identified and the training module is included for the instructor.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2020

San Diego State University is revising its current process to ensure that departments are using student safety training acknowledgement forms and are complying with the retention requirements for these forms. Environmental Health and Safety Department will perform these reviews at least annually as required.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2019

The recommendation has been fully implemented. Reviews have been performed to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirements. Environmental Health and Safety Department (EHS) has established a notification process at the beginning of each semester reminding Department Chairs and School Directors to provide safety training to students attending specifically identified courses. Signed forms are collected and held at designated departments. EHS compliance officers review the safety training acknowledgement forms after SDSU's add/drop deadline to ensure that forms are completed and that the academic departments are complying with the retention requirements.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

San Diego implemented a policy stating that it will perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms, and demonstrated it has completed such reviews. However, the policy does not state that the reviews will also ensure that departments are complying with the retention requirement.

1-Year Agency Response

Implementation of annual reviews is in progress.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

Implementation is in progress and the annual reviews will begin in Spring 2019.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Implementation is in progress. Reviews will be performed at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #57 To: Sonoma State University

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sonoma should perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

Annual Follow-Up Agency Response From October 2019

Sonoma State University implemented procedures to review that departments are using student safety training acknowledgement forms as required by the Chemical Hygiene Plan. The procedures also include documentation and retention requirements.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Sonoma provided evidence demonstrating that in April and October 2019 it performed a review to ensure that departments are using and retaining the student training acknowledgement forms. It also provided evidence demonstrating that it revised its Chemical Hygiene Plan to include the requirement for Sonoma to perform reviews annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

1-Year Agency Response

SSU has developed and implemented a student safety in laboratory curriculum.

California State Auditor's Assessment of 1-Year Status: Pending

Although Sonoma provided evidence demonstrating that in April 2019 it performed a review to ensure that departments are using the student training acknowledgement forms, it did not provide evidence that it plans to do so at least annually or that its review ensures that departments are complying with the retention requirement.

6-Month Agency Response

The campus has begun collecting student training acknowledgement forms beginning in the Fall 2018 semester. The secondary review of student training acknowledgement forms for the Fall 2018 semester is scheduled for December 2018.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The university will annually review all departments to ensure the student training acknowledgement forms are completed and compliance with the retention requirement in August 2018 as recommended.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #58 To: University, California State

As part of the uniform health and safety-reporting template that we recommend that it develop, the Chancellor's Office should require campuses to annually report on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems and identify the reasons for any delays.

Annual Follow-Up Agency Response From October 2020

The current annual reporting template requires campuses to report on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems and identify the reasons for any delays.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

The Chancellor's Office developed and distributed a uniform health and safety reporting template which requires information regarding the timeliness of various inspections and the reasons for any delays. In addition, the Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we will begin any necessary follow up with the campuses.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

The Chancellor's Office developed a new health and safety reporting template which requires information regarding the timeliness of various inspections and the reasons for any delays. In addition, the Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting the reports in November 2019. Once the reports are received, we will begin any necessary follow up with the campuses.

In the meantime, the Chancellor's Office updated an existing contract to deploy a comprehensive software suite for campuses to use for assessing risks and inspecting relevant laboratory and work spaces. All campuses have incorporated software to help address previous challenges and develop consistency in documentation. Campus employees are being trained on the use of the software and are in various states of implementation. We anticipate that all campuses will be engaged in this level of recordkeeping by the end of June 2019.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The Chancellor's Office has begun the process of developing a new health and safety reporting template; the template will require information regarding the timeliness of various inspections and the reasons for any delays. In addition, the Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting the reports in September 2019. Once the reports have been received, we will begin any necessary follow up with the campuses.

In the meantime, the Chancellor's Office has updated an existing contract to deploy a comprehensive software suite for campuses to use for assessing risks and inspecting relevant laboratory and work spaces. The software will help address previous challenges with consistency and documentation requirements. We anticipate that all campuses will begin using the system by early 2019.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The Chancellor's Office has begun the process of developing a new health and safety reporting template; the template will require information regarding the timeliness of various inspections and the reasons for any delays. In addition, the Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting the reports in September 2019. Once the reports have been received, we will begin any necessary follow up with the campuses.

In the meantime, the Chancellor's Office is updating an existing contract to deploy a comprehensive software suite for campuses to use for assessing risks and inspecting relevant laboratory and work spaces. The software will help address previous challenges with consistency and documentation requirements.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #59 To: University, California State

Based on campuses annual reports on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems, the Chancellor's Office should follow up with campuses that report untimely inspections and should require that the campuses develop action plans to ensure that they complete inspections as often as state regulations require.

Annual Follow-Up Agency Response From October 2021

The annual reporting template requires campuses to report on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems and identify the reasons for any delays.

Systemwide Risk Management at the Chancellor's Office continues to monitor and evaluate the information in the annual reports and provide feedback to the campuses on areas that need improvement.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2020

The current annual reporting template requires campuses to report on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems and identify the reasons for any delays. After receiving the data from the first annual reports in 2019, it was determined that more detailed and meaningful data is needed to help the campuses develop action plans to ensure they are in compliance with state regulations. Systemwide Risk Management will continue to work with the campuses on this issue.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2019

The Chancellor's Office developed and distributed a uniform health and safety reporting template which requires information regarding the timeliness of various inspections and the reasons for any delays. In addition, the Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. Campuses will begin submitting reports using the new template (or their own report format as long as the reports include the required data) in November 2019. Once those reports are received by the Chancellor's Office, we will begin any necessary follow up with the campuses.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

The Chancellor's Office developed a new health and safety reporting template which requires information regarding the timeliness of various inspections and the reasons for any delays. In addition, the Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting the reports in November 2019. Once the reports are received, we will begin any necessary follow up with the campuses. In addition, a new Systemwide Environmental Health and Safety Manager started work at the Chancellor's Office on December 17, 2018; his duties include consulting with the campuses as well as conducting follow up on compliance issues.

Further, the Chancellor's Office updated an existing contract to deploy a comprehensive software suite for campuses to use for assessing risks and inspecting relevant laboratory and work spaces. All campuses have incorporated software to help address previous challenges and develop consistency in documentation. Campus employees are being trained on the use of the software and are in various states of implementation. We anticipate that all campuses will be engaged in this level of recordkeeping by the end of June 2019.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The Chancellor's Office has begun the process of developing a new health and safety reporting template; the template will require information regarding the timeliness of various inspections and the reasons for any delays. In addition, the Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting the reports in September 2019. Once the reports have been received, we will begin any necessary follow up with the campuses. In addition, the Chancellor's Office is in the final stages of recruiting a Systemwide EH&S Manager, whose duties will include consulting with the campuses as well as conducting follow up on compliance issues. The finalists were interviewed on October 23, 2018.

In the meantime, the Chancellor's Office has updated an existing contract to deploy a comprehensive software suite for campuses to use for assessing risks and inspecting relevant laboratory and work spaces. The software will help address previous challenges with consistency and documentation requirements. We anticipate that all campuses will begin using the system by early 2019.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The Chancellor's Office will follow up with campuses that report untimely inspections to ensure they develop action plans to address any delays. The Chancellor's Office anticipates that the reporting template will be implemented for fiscal year 2018-19, with campuses submitting the reports in September 2019. Once the reports have been received, we will begin any necessary follow up with the campuses.

In the meantime, the Chancellor's Office is updating an existing contract to deploy a comprehensive software suite for campuses to use for assessing risks and inspecting relevant laboratory and work spaces. The software will help address previous challenges with consistency and documentation requirements.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #60 To: University, California State

To ensure compliance with state requirements to notify employees about the presence of asbestos, the Chancellor's Office should immediately remind all of its campuses that state regulations require posting signage at the entrances to mechanical rooms that contain asbestos.

60-Day Agency Response

In May 2018 the Chancellor's Office reminded all of the campuses that state regulations require posting signage at entrances to mechanical rooms that contain asbestos.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

The Chancellor's Office provided evidence demonstrating that in May 2018 it sent a memo to remind all of its campuses that state regulations require posting signage at the entrances to mechanical rooms that contain asbestos.

Recommendation #61 To: University, California State

To ensure compliance with state requirements to notify employees about the presence of asbestos, the Chancellor's Office should, by September 2018, ensure that campuses are compliant with the requirement to post warning signage at the entrances to mechanical rooms that contain asbestos.

Annual Follow-Up Agency Response From October 2020

All 23 campuses certified that they are in compliance with state regulations that require posting signage at entrances to mechanical rooms that contain asbestos. In addition, as part of the 2019 audit plan, the division of Audit and Advisory Services completed health and safety audits at all 23 campuses and the Chancellor's Office, including a step to confirm the campuses were in compliance with the signage requirements.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

As part of the health and safety audits being conducted at all campuses in 2019 by the division of Audit and Advisory Services, the audit teams independently verified each campus's compliance with this requirement.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

The Chancellor's Office provided evidence that it has conducted or began conducting audits of all 23 campuses to ensure that campuses are compliant with the requirement to post warning signage at the entrances to mechanical rooms that contain asbestos. However, we will report this recommendation as not fully implemented until the Chancellor's Office completes audits of all campuses and ensures they are compliant with this requirement.

1-Year Agency Response

All 23 campuses certified that they are in compliance with state regulations that require posting signage at entrances to mechanical rooms that contain asbestos.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Although the Chancellor's Office provided evidence demonstrating that it ensured that all required campuses stated that they are compliant with the requirement to post warning signage at the entrances to mechanical rooms that contain asbestos, it did not demonstrate that it independently verified that the campuses posted the warning signs as required.

6-Month Agency Response

Currently, 21 of the 23 campuses have certified that they are in compliance with state regulations that require posting signage at entrances to mechanical rooms that contain asbestos. The Chancellor's Office is working with the remaining two campuses to ensure that the required asbestos warning signs are posted.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

In May 2018 the Chancellor's Office reminded all of the campuses that state regulations require posting signage at entrances to mechanical rooms that contain asbestos. We are in the process of ensuring that campuses have complied with that requirement.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #62 To: Sacramento, California State University

Sacramento should monitor the implementation of its new processes for inspecting safeguards to ensure that it completes monthly flushes of eyewashes and showers as state regulations require.

Annual Follow-Up Agency Response From October 2020

Sacramento State has continued to monitor its processes for flushing eyewashes and safety showers to ensure these flushes occur monthly as required and none are missed.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

Sacramento State has continued to monitor its processes for flushing safety showers and implemented a new, more centralized process for flushing eyewashes to ensure these flushes occur monthly as required and none are missed.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Beginning with October 2019, Sacramento implemented a new centralized process for monthly inspection of eye wash stations. However, because Sacramento has only conducted such inspections for one month as of its response date, we cannot determine whether it has fully implemented our recommendation.

1-Year Agency Response

Sacramento State is monitoring, and will continue to monitor, the implementation of its new processes for inspecting safeguards to ensure that it completes monthly flushes of eyewashes and showers as state regulations require. The campus Chemical Hygiene Officer continues to conduct regular inspections of laboratory spaces that include checking the timely testing of eyewashes.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Sacramento has provided evidence that it verifies the monthly flushes of eyewashes. It also provided additional evidence demonstrating that it created work orders to monitor and ensure that it inspects and flushes showers monthly as state regulations require. However, its monitoring shows that it has missed some of the required eyewash flushes. As its monitoring has not yet ensured that it complies with the required monthly flushes, we assess this recommendation as partially implemented.

6-Month Agency Response

Sacramento State is monitoring, and will continue to monitor, the implementation of its new processes for inspecting safeguards to ensure that it completes monthly flushes of eyewashes and showers as state regulations require. Specifically, the campus created a work order for monthly tests of safety showers, which management reviews to ensure the testing has been completed. The campus also implemented a process whereby the Chemical Hygiene Officer conducts regular inspections of laboratory spaces that include verifying the functionality and timely testing of safety showers and eyewashes.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Sacramento provided evidence demonstrating that it created work orders to monitor and ensure that it inspects and flushes showers monthly as state regulations require. However, it did not provide evidence that it verifies the monthly flushes of eyewashes that state regulations require.

60-Day Agency Response

Sacramento State is putting processes in place to monitor eyewash and safety shower flushes to ensure they occur as state regulations require. Facilities Management has created a work order for monthly tests of safety showers, and management will review the work orders each month to ensure the testing has been completed. In addition, the Chemical Hygiene Officer will complete monthly walk-through inspections of laboratory spaces to confirm compliance with eyewash and safety shower flush requirements.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #63 To: Sacramento, California State University

Sacramento should immediately assess the health and safety risks in its art sculpture lab and take action to ensure that safeguards are readily accessible as state regulations require.

1-Year Agency Response

Sacramento State determined that the assessment report previously provided erroneously indicated the presence of chemicals in the art sculpture lab that can cause severe irritation. The EH&S director confirmed that the chemicals in question do not, in fact, cause the level of irritation requiring the installation of an eyewash station and prepared a revised report to correct the error.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

For its six-month response, Sacramento State provided evidence that its EH&S director assessed the health and safety risks in its art sculpture lab and concluded that no chemicals were present that required the installation of eyewash stations. However, the assessment report it provided indicates that one of the rooms in its art sculpture lab does have chemicals present that can cause severe irritation.Sacramento State provided an updated assessment report that indicates that none of the rooms in its art sculpture lab have chemicals present that can cause severe irritation.

6-Month Agency Response

Sacramento State has re-assessed and more fully documented the health and safety risks presented by the chemicals in the art sculpture lab. As with the previous assessment, the campus determined that the space complies with state regulatory requirements for safeguards as regulations do not require an eyewash station for the chemicals currently being used in the lab.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Sacramento provided evidence that its EH&S director assessed the health and safety risks in its art sculpture lab and concluded that no chemicals were present that required the installation of eyewash stations. However, the assessment report it provided indicates that one of the rooms in its art sculpture lab does have chemicals present that can cause severe irritation. Until it provides evidence that it has addressed this risk, we consider this recommendation as only partially implemented.

60-Day Agency Response

Sacramento State has assessed the health and safety risks in the art sculpture lab and determined that the space complies with state regulatory requirements for safeguards as regulations do not require an eyewash station for the chemicals currently being used in the lab. Nevertheless, the campus has made eyewash bottles available in the lab. Additionally, the campus is in the process of assessing the art sculpture lab for improvements to further enhance the safety of the space.

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Sacramento provided a memo from its EH&S director indicating that he assessed the health and safety risks in its art sculpture lab and concluded that no chemicals were present that required the installation of eyewash stations. However, Sacramento did not provide actual evidence of this assessment and, until it does so, we will report this recommendation as partially implemented. Sacramento provided evidence demonstrating that the campus has made eyewash bottles available in the lab.

Recommendation #64 To: San Diego, California State University

San Diego should immediately develop and implement a plan to ensure that it consistently completes its flushes of eyewashes and showers monthly as state regulations require.

1-Year Agency Response

Emergency eyewash and showers are now flushed on a monthly basis. Facilities Services' written plan and procedures include: an inventory of eyewash stations with identifying asset tag numbers, a sample Preventive Maintenance Work Order and Corrective Action Work Order reports from the AiM system, and samples of Eye Wash Shower Inspection Records affixed to equipment.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

Emergency eyewash and showers are currently flushed on a monthly basis as required. A written plan was developed and was implemented by Facilities Services.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

San Diego provided a memo from its EH&S associate director stating that a meeting took place between EH&S and Facilities Services to finalize their discussion about implementing a plan to ensure it flushes emergency eyewash and shower stations monthly as state regulations require. The memo also describes how Facilities Services assigns the monthly flush work and that it will report deficiencies to EH&S. However, San Diego did not provide evidence it followed through with this plan. Accordingly, we assess this recommendation as partially implemented.

60-Day Agency Response

Emergency eyewash and showers are currently flushed on a monthly basis as required. Written plan is in progress and is being developed by Facilities Services.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #65 To: Sonoma State University

Sonoma should continue to implement and adhere to its plan to ensure that it flushes showers and eyewashes and that it inspects fire extinguishers monthly as state regulations require.

Annual Follow-Up Agency Response From October 2019

Sonoma State University has implemented its plan to ensure that it flushes showers and eyewash stations and that it inspects fire extinguishers monthly as state regulations require. All procedures are being performed monthly as assigned in our work order system.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Sonoma provided inspection documentation demonstrating that it flushes showers and eyewashes and that it inspects fire extinguishers monthly as state regulations require.

1-Year Agency Response

Sonoma State University is continuing to adhere to our plan concerning eyewash/safety showers and fire extinguishers. A recurring monthly Work Order is generated ensuring a tradesman is assigned to complete the task.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Sonoma provided documentation demonstrating that it flushed showers and eyewash stations in March, April, and July 2018 through March 2019, and inspected some fire extinguishers between May and July 2018. However, it did not provide evidence to demonstrate that it inspected fire extinguishers in other months or in 2019, which makes it difficult to know if Sonoma has consistently complied with the requirement to inspect this equipment monthly.

6-Month Agency Response

The university has implemented its plan to ensure that it flushes showers and eyewash stations and that it inspects fire extinguishers monthly as state regulations. The procedures are being conducted monthly as assigned in work order system, documented on site, and the semi annual inspection forms now include verifying monthly checks are complete.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Sonoma provided documentation demonstrating that it flushed showers and eyewash stations in October 2018 and inspected fire extinguishers in July 2018. However, it did not provide evidence to demonstrate that it conducted these flushes and inspections in other months, which makes it difficult to know if Sonoma has consistently complied with the requirement to inspect and flush this equipment monthly.

60-Day Agency Response

The university is implementing its plan to ensure that it flushes showers and eyewash stations and that it inspects fire extinguishers monthly as state regulations.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #66 To: Sonoma State University

Sonoma should add preventative maintenance work orders to its work order system by September 2018 to ensure that it completes fume hood and biosafety cabinet inspections annually as state regulations require.

Annual Follow-Up Agency Response From October 2019

Sonoma State University utilizes a work order system to ensure compliance with preventative maintenance of systems on campus. In Spring 2019, Sonoma State University moved to a new work order system that is more robust and provides greater integration with the facility maintenance work flow. We were converting all work orders from the retired work order system to the new work order system during the April 2019 response date. Work orders for the fume hoods and biosafety cabinets are now included in the new system to ensure inspection and maintenance of those systems is performed annually and documented.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Sonoma provided evidence demonstrating that it implemented preventative maintenance work orders to ensure that it completes fume hood and biosafety cabinet inspections annually as state regulations require.

1-Year Agency Response

SSU has added this to the Work Order System to ensure it is completed annually.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Although Sonoma provided evidence demonstrating that it had completed fume hood and biosafety cabinet inspections, it did not provide evidence that it added preventative maintenance work orders to its work order system to ensure that it consistently completes fume hood and biosafety cabinet inspections annually as state regulations require.

We assessed Sonoma's 6-month response as partially implemented because it did not provide evidence that it added preventative maintenance work orders to its work order system to ensure that it completes fume hood and biosafety cabinet inspections annually as state regulations require in its main science building. It still has not provided this evidence and until it does so, we will continue to assess this recommendation as partially implemented.

6-Month Agency Response

The university has added preventative maintenance work orders into its work order system. All fume hoods and biosafety cabinets inspections are current and will be re-certified annually.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Sonoma provided evidence that it added preventative maintenance work orders to its work order system to ensure that it completes fume hood and biosafety cabinet inspections annually as state regulations require in its art building and one science building. However, it did not provide evidence demonstrating that it did so for its main science building.

60-Day Agency Response

The university will add preventative maintenance work orders into its work order system by September 2018 semester as recommended.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #67 To: San Diego, California State University

San Diego should continue to implement its new policy to regularly review open work orders to ensure that it closes work orders in a timely fashion.

Annual Follow-Up Agency Response From November 2020

San Diego State University has implemented, in Fall 2020, its aging work order management process to ensure open work orders are regularly reviewed and closed timely. Work order projects are now categorized, assigned, numbered, and tracked through the computerized maintenance management system (CMMS). Documented reviews are regularly conducted, and quarterly reports are reviewed by administrative level management to ensure that any delays are noted in the CMMS. Any aged work orders that remain open without sufficient reason will be closed out and if a closed project must be reinstated, a new work order must be submitted.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

San Diego provided evidence demonstrating that it implemented a new policy in September 2020 to regularly review open work orders to ensure that it closes work orders in a timely fashion.

Annual Follow-Up Agency Response From October 2019

Facilities Services has implemented a process for Management to review all outstanding work orders every 45 days. The computerized maintenance management system is updated with notes as work orders progress so that status can be tracked/audited. Work orders over 60 days are reviewed monthly for status updates. Facilities Services is in the final stages of monitoring this process to ensure continuity and support documents will be provided with final audit response.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

Implementation is in progress.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

Facilities Services continues to actively develop written processes and procedures to assure work orders are closed in a timely fashion. The initial approach includes two levels of oversight, established target time-frames for closing of work orders, and re-focusing of staff on work order management.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Facilities Services continues to actively develop written processes and procedures to assure work orders are closed in a timely fashion. The initial approach includes two levels of oversight, established target time-frames for closing of work orders, and re-focusing of staff on Work Order management.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #68 To: San Diego, California State University

San Diego should immediately develop and implement a plan to ensure that it consistently completes its inspections of air handler units at least annually.

1-Year Agency Response

SDSU has developed and implemented a plan to ensure that it consistently completes its inspections of air handler units at least annually.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

San Diego provided evidence demonstrating that it developed and implemented a plan to ensure that it consistently completes its inspections of air handler units at least annually.

6-Month Agency Response

Facilities Services is developing a comprehensive program to assure timely work order completion for critical tasks including air handler inspection. Processes will include at least annual reporting and employees will be trained on procedures and prioritization of critical tasks.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Facilities Services is developing a comprehensive program to assure timely work order completion for critical tasks including air handler inspection. Processes will include at least annual reporting and Shops' employees will be trained on procedures and prioritization of critical tasks.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #69 To: Sonoma State University

By September 2018, Sonoma should begin using its work order management system to track and ensure preventative maintenance inspections of air handler units are completed at least annually.

Annual Follow-Up Agency Response From October 2019

Sonoma State University has implemented its plan to use its new work order management system to track and ensure preventative maintenance inspections for air handler units are completed annually. We documented compliance with the inspection requirements in Fall 2018 and inspections are scheduled again in Fall 2019.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Sonoma provided evidence that it began using its work order management system to track preventative maintenance inspections of air handler units, and that inspections of the air handler units are completed at least annually.

1-Year Agency Response

SSU has added inspections of air handler units to its' Work Order System to ensure it is completed annually.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Sonoma provided evidence that it began using its work order management system to track preventative maintenance inspections of air handler units. However, it did not provide evidence that all inspections are current. The work order report it provided only shows that it created the work orders to inspect air handler units and completed some inspections, but it does not show that it completed all of the inspections.

6-Month Agency Response

The university uses its work order management system to track and ensure preventative maintenance inspections of air handler units are completed at least annually by September 2018 as recommended. All inspections are current and will continue to be conducted annually.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Sonoma provided evidence that it began using its work order management system to track preventative maintenance inspections of air handler units. However, it did not provide evidence that all inspections are current. The work order report it provided only shows that it created the work orders to inspect air handler units, but it does not show that it completed the inspections.

60-Day Agency Response

The university use its work order management system to track and ensure preventative maintenance inspections of air handler units are completed at least annually by September 2018 as recommended.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #70 To: Channel Islands, California State University

Channel Islands should immediately begin following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. Further, Channel Islands should amend its chemical plan to include specific expectations about how often departments and its EH&S office will conduct self-audits.

Annual Follow-Up Agency Response From October 2020

Channel Islands implemented its departmental self-audits to identify and address safety concerns in its laboratories. The amended chemical plan includes specific expectations about how often departments and its EH&S office will conduct self-audits. The memo specifies due dates for inspections.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2019

Fully Implemented: Channel Islands has implemented departmental self-audits to identify and address safety concerns in its laboratories. Furthermore, Channel Islands amended its chemical plan to include specific expectations about how often departments and its EH&S office will conduct self-audits. We issued a memo clarifying the inspection times for Spring and Fall to take effect next semester. The changes will be fully implemented by close of the Fall 2020 semester.

Completion date: November 2019

Response date: November 2019

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Although Channel Islands has clarified its policy for the timing of inspections, as it indicates in its response, Channel Islands has not yet fully implemented the new policy.

1-Year Agency Response

The campus issued a self-audit directive on June 18, 2018. For Risk and Safety Solutions (RSS) assessment and inspections modules, trainings for faculty and staff are available online. A memo was sent to relevant faculty and staff on September 6, 2018 announcing the availability of the RSS trainings and directions for how to access the trainings. The campus is implementing enforcement of the requirement.

The Environmental Health and Safety (EHS) department has attached the Provost's June 2018 directive requiring semi-annual self-audits to the revised Chemical Hygiene Plan (CHP). The CHP appendices also include a self-audit lab safety checklist.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Channel Islands provided evidence demonstrating that it amended its chemical plan to include specific expectations about how often departments and its EH&S office will conduct self-audits.

However, Channel Islands did not provide evidence demonstrating that it began following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories.

6-Month Agency Response

The campus issued a self-audit directive on June 18, 2018. Risk and Safety Solutions (RSS) training -- including coverage of self-audits in the inspection module -- is available to faculty and staff online. Academic Affairs is currently working to finalize delegation of implementation responsibilities.

Environment, Health and Safety (EHS) has completed an updated draft Chemical Hygiene Plan (CHP) to include the requirement that self-audits be completed on a semi-annual basis. Currently, EHS is engaged in discussions with various labor unions to finalize the CHP.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Channel Islands has begun the process to follow policies regarding departmental self-audits. In June 2018, the Provost sent a memo to all department chairs over academic programs requiring self-audits. The memo states that, effective immediately, self-audits will be conducted once per semester.

The campus has an updated draft Chemical Hygiene Plan which reflects semi-annual completion of self-audits, however, the campus is in the process of working with the various unions for approval of this update to the CHP.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #71 To: Sonoma State University

Sonoma should immediately begin following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. Further, Sonoma should ensure that its self-audits review whether timely flushes of eyewashes and showers have occurred. As part of self-audits, Sonoma's departments should ensure that fume hoods have received annual inspections. Finally, Sonoma's EH&S department should regularly review whether departments are conducting self-audits.

Annual Follow-Up Agency Response From October 2020

Sonoma State University conducts departmental self-audits each semester to identify and address safety concerns in its laboratories, including the confirmation of timely flushing of eyewashes and showers and to ensure that fume hoods have received annual inspections. Representatives from our EH&S department regularly review the departmental self-audits to ensure compliance and provide guidance for items in need of corrective action.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Sonoma provided evidence demonstrating that it began following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. In addition, it provided evidence demonstrating that those self-audits include a review of whether timely flushes of eyewashes and showers have occurred, as well as whether fume hoods have received annual inspections. Sonoma also provided evidence that its EH&S department regularly reviews whether departments are conducting self-audits.

Annual Follow-Up Agency Response From October 2019

Sonoma State University consistently conducts departmental self-audits to identify and address safety concerns in its laboratories and the timely flushing of eyewashes and showers. The self-audits also ensure that fume hoods have received annual inspections. Our EH&S department regularly reviews the departmental self-audits as is evidenced by our Chemical Lab, Art Studio, & Shop Inspection Checklist.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Sonoma provided evidence demonstrating that it began following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. Although Sonoma provided evidence demonstrating that those self-audits review whether timely flushes of eyewashes and showers have occurred, and whether fume hoods have received annual inspections, it did not provide evidence demonstrating that its EH&S department regularly reviews whether departments are conducting self-audits.

1-Year Agency Response

SSU has implemented the RSS software that has an inspection module in it. Some of the staff are utilizing the inspection module however, due to the complexity and newness of the program others have opted for an alternate inspection form to be utilized.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Although Sonoma provided evidence demonstrating that it began following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories, it did not provide evidence demonstrating that it consistently does so. In addition, although it provided evidence demonstrating that those self-audits review whether timely flushes of eyewashes and showers have occurred, it did not provide evidence demonstrating that as a part of its self-audits, its departments review whether fume hoods have received annual inspections or that its EH&S department regularly reviews whether departments are conducting self-audits.

6-Month Agency Response

The campus is currently working on implementing a comprehensive software solution to coordinate, schedule, and monitor the self-audit requirement.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The university is evaluating an inspection software solution for self-audit tracking and monitoring. The university had its fume hoods inspected in December 2017 and will ensure this inspection occurs annually as required.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #72 To: Sacramento, California State University

Sacramento should immediately begin following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. Further, Sacramento should ensure that its self-audits review whether timely flushes of eyewashes and showers have occurred.

6-Month Agency Response

Sacramento State completed departmental self-audits to identify and address safety concerns in its laboratories. The self-audits reviewed whether timely flushes of eyewashes and showers occurred. Self-audits will continue to take place at least once per semester as required by campus policy.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Sacramento provided evidence that it conducts departmental self-audits to identify and address safety concerns in its laboratories and that its self-audits review whether timely flushes of eyewashes and showers have occurred. So long as Sacramento continues this practice, it will fully implement our recommendation.

60-Day Agency Response

Sacramento State is committed to following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. The campus Environmental Health and Safety office has met with departments that use laboratories to remind them of self-audit requirements, including the requirement to review whether timely flushes of eyewashes and showers have occurred, and to identify who will be responsible for ensuring self-audits occur. Sacramento State will follow up with these departments to ensure that departmental self-audits are occurring.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #73 To: San Diego, California State University

San Diego should ensure that it documents all self-audits it conducts, including when it does not identify any violations during the audit. Further, San Diego should continue to implement and follow its new process to include reviews of safeguard inspections as a part of its self-audits.

Annual Follow-Up Agency Response From November 2020

San Diego State University has revised its process for documenting all self-audits and now requires notations, including when it does not identify any violations. EH&S now uses a new software application, "Fulcrum" on mobile devices to document inspection results, even when it does not identify any violations.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

San Diego provided evidence demonstrating that it now requires EH&S to document all self-audits it conducts, including when it does not identify any violations during the audit. In addition, San Diego provided evidence demonstrating that it has continued to implement and follow its new process to include reviews of safeguard inspections as a part of its self-audits.

Annual Follow-Up Agency Response From October 2019

The campus has implemented documenting all self-audits, including when it does not identify any violations. Currently SDSU is utilizing a new software application, Risk and Safety Solutions, to better document compliance inspections of laboratory and workshop facilities. Environmental Health and Safety Department (EHS) Compliance Officers conduct inspections three times yearly. Non-compliance items should be resolved within 30 days. Corrections to non-compliance issues are noted by the responsible person designated for each laboratory facility or workshop area on the inspection reports. Compliance officers review or physically verify the corrections, if warranted. Compliance officers monitor unresolved non-compliance issues and will elevate to Department Chair or higher if necessary.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

San Diego implemented procedures that outline the responsibility for the compliance officer to conduct self-audits, including reviews of safeguard inspections, and document the results in a report. However, the procedures do not indicate that the compliance officer will document the results even when it does not identify any violations.

1-Year Agency Response

Implementation is in progress.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

Implementation is in progress. The campus has started documenting all self-audits, including when it does not identify any violations. The campus will continue to include reviews of safeguard inspections as a part of its self-audits. The campus will also implement and utilize a new software application, Risk Safety Solution, provided by the Chancellor's Office to document inspections.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Implementation is in-progress. The campus will document all self-audits, including when it does not identify any violations. The campus will also continue to include reviews of safeguard inspections as a part of its self-audits.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #74 To: San Diego, California State University

San Diego should immediately ensure that the entrances to all mechanical rooms with asbestos or material presumed to contain asbestos have signage to inform employees about the presence of the hazardous substance.

6-Month Agency Response

The Interim Director - Facilities Services has confirmed that signage for all mechanical room entrances with asbestos or material presumed to contain asbestos has been posted to inform employees of the hazardous substances.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

San Diego provided evidence that it placed the required warning signs at the entrances to the mechanical rooms with asbestos or material presumed to contain asbestos that we identified during our audit as not having the required signage. It also provided an email from the interim director of Facilities Services stating that he had placed the required warning signs inside and at the entrances to all mechanical rooms with asbestos or material presumed to contain asbestos. Provided that this is true, we consider this recommendation to be fully implemented.

60-Day Agency Response

Implementation in progress. Signage for 30 mechanical rooms has been ordered and installation by Facilities Services will begin when received.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #75 To: Sacramento, California State University

Sacramento should immediately ensure that the entrances to all mechanical rooms with asbestos or material presumed to contain asbestos have signage to inform employees about the presence of the hazardous substance.

60-Day Agency Response

Sacramento State has ensured that the entrances to all mechanical rooms with asbestos or material presumed to contain asbestos have signage to inform employees about the presence of the hazardous substance.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

All Recommendations in 2017-119

Agency responses received are posted verbatim.