2024-115 The Division of Occupational Safety and Health
Process Deficiencies and Staffing Shortages Limit Its Ability to Protect Workers
Published: July 17, 2025
Audit Recommendations Disclosure
When an audit is completed and a report is issued, auditees must provide the State Auditor with information regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year. Additionally, Senate Bill 1452 (Chapter 452, Statutes of 2006), requires auditees who have not implemented recommendations after one year, to report to us and to the Legislature why they have not implemented them or to state when they intend to implement them. Below is a listing of each recommendation the State Auditor made in the report referenced and a link to the most recent response from the auditee addressing their progress in implementing the recommendation and the State Auditor’s assessment of auditee’s response based on our review of the supporting documentation.
Recommendations to Cal/OSHA
Recommendation 1
To ensure that enforcement personnel conduct on-site inspections of complaints when circumstances warrant inspections, Cal/OSHA should, by July 2026, revise its policies and procedures in the following ways:
- Require personnel to provide a thorough rationale—for example, more than a short phrase—that explains how their decision not to conduct an on-site inspection aligns with specific policy requirements. Cal/OSHA should also specify how or where personnel should document this rationale in the case file.
- Place more emphasis on factors other than the source of a complaint when determining whether to inspect on-site—such as the severity of the allegations, the employer’s history, and the potential benefits or drawbacks of an on-site inspection relative to the circumstances of the complaint—and specify that personnel should not investigate a complaint by letter simply because the complainant wishes to remain anonymous.
- Describe the steps personnel should take, such as contacting the regional manager to try to obtain additional resources, when staffing shortages may limit a district office’s ability to inspect a complaint on-site.
Agency response status:
Pending
Recommendation 2
To ensure that letter investigations effectively address hazards, Cal/OSHA should, by July 2026, revise its policies and procedures in the following ways:
- Explicitly require enforcement personnel to include supporting documents from employers, in addition to employers’ written responses, in the case file before closing a letter investigation. These supporting documents should prove that employers have adequately responded to each alleged hazard. Cal/OSHA should also ensure that personnel evaluate the employer responses and supporting documents consistently, such as by providing guidelines or training for doing so.
- Outline a method to verify that employers receive Cal/OSHA’s letters in a timely manner, such as by instructing personnel to send letter investigations to employers by email and to document when the employers received them. If personnel do not have an email address for the employer, Cal/OSHA should consider requiring personnel to call the employer to verify the mailing address.
- Clarify that district offices should conduct the follow-up inspections of satisfactory employer responses that are currently optional, unless the offices notify enforcement branch leadership or otherwise document that they do not have enough staff available to do the inspections.
Agency response status:
Pending
Recommendation 3
To ensure that it makes appropriate decisions about which accidents to investigate, Cal/OSHA should, by July 2026, update its policies and procedures to include the factors that personnel should consider when determining whether to investigate a reported accident and how to appropriately explain and document these factors in the case file. These factors should include, at a minimum, the following:
- Whether state law or other Cal/OSHA policies require an investigation. Cal/OSHA should also specify how to document this factor, such as by including in the case file medical records or other evidence proving that a worker did not suffer a serious injury or illness or by including a rationale for why an investigation of a serious injury or illness is unnecessary.
- Whether an investigation would be beneficial even if one is not mandatory. For example, personnel could consider the likelihood that an inspection would identify workplace violations and help prevent future accidents, and they could weigh the potential benefits of an inspection against the district office’s other priorities. As part of these policy revisions, Cal/OSHA should explicitly include a process for investigating reported accidents that do not meet the threshold of a serious injury or illness in state law, such as by including these types of cases in its prioritized list of on-site inspection types.
Agency response status:
Pending
Recommendation 4
To improve its evaluation of employers’ injury and illness prevention programs (IIPPs) and to ensure that these programs adequately protect workers, Cal/OSHA should, by July 2026, revise its policies and procedures to specify how personnel should document IIPP evaluations in the case file. Such procedures should include how personnel should document an assessment of the employer’s written IIPP and of the employer’s implementation of the IIPP in practice. Cal/OSHA should also consider distributing to enforcement personnel a unified form or template for documenting a thorough IIPP evaluation.
Agency response status:
Pending
Recommendation 5
To ensure that enforcement personnel interview an adequate sample of employees, Cal/OSHA should, by July 2026, revise its policies and procedures to clarify how personnel should determine the number and type of employees to interview.
Agency response status:
Pending
Recommendation 6
To ensure that enforcement personnel document interviews effectively, Cal/OSHA should, by July 2026, provide training or take other steps to ensure that personnel are aware of its interview documentation policies and either record audio of interviews, obtain signed statements from workers, or take legible notes. In addition, Cal/OSHA should revise its policy to require enforcement personnel to document in the case file when a worker has declined Cal/OSHA’s request to record an interview.
Agency response status:
Pending
Recommendation 7
To ensure that case files include the evidence necessary to support the citations it issues, Cal/OSHA should, by July 2026, establish a policy or process for enforcement personnel to internally review and discuss the evidence supporting potential violations in each on-site inspection while there is still time to gather additional evidence, such as at the two- or three-month mark of a six-month inspection. These reviews should include the violation worksheets and evidence supporting potential violations. Cal/OSHA should also develop a method for tracking these reviews, such as automated reminders to have them.
Agency response status:
Pending
Recommendation 8
To ensure that it conducts on-site inspections in a timely manner, Cal/OSHA should, by July 2026, revise its policies and procedures to establish and implement goal time frames in which it expects personnel to initiate inspections of non-fatal accidents and of complaints—other than imminent hazard complaints—that fall outside of the purview of Labor Code section 6309.
Agency response status:
Pending
Recommendation 9
To ensure that employers abate hazardous conditions that Cal/OSHA’s inspections identify, Cal/OSHA should, by July 2026, revise its policies and procedures to require enforcement personnel to do the following:
- Request and document in the case file supporting evidence beyond signed certifications—such as photographs, detailed inspector observations, or other records—proving that the employer abated each violation that Cal/OSHA classifies as serious, repeat, or willful. Cal/OSHA should also consider whether such supporting evidence of abatement is advisable for non-repeat and non-willful general violations and, to the extent Cal/OSHA deems it necessary, request changes to state law or regulations to grant it the authority to request this evidence from employers.
- Document in each accident case file the accident’s causes or contributing factors that enforcement personnel have uncovered during the inspection and, when the causes or factors are reasonably related to a workplace violation, document an explanation of how the employer’s abatement efforts have addressed each of these causes or factors and mitigated the likelihood of future accidents occurring. Cal/OSHA should require that personnel document these items even for accidents that occurred at temporary worksites.
Agency response status:
Pending
Recommendation 10
To ensure that it assesses fines appropriately, Cal/OSHA should, by July 2026, revise its policies and procedures to require the following:
- Enforcement personnel must document rationales and evidence supporting the classifications and adjustment factors they apply for each fine—including rationales supporting that a violation is or is not accident-related—and specify where in the case file personnel should provide this information. For example, Cal/OSHA could require that personnel use the existing violation worksheets but include specific reasoning to support each classification and factor.
- Staff must document rationales for all post-citation fine reductions, including those made outside of an informal conference meeting, and must also document supporting evidence when it helps demonstrate the reasonableness of the reductions. Cal/OSHA should specify whether these rationales and supporting evidence should be documented in the enforcement case file or whether some rationales that are protected by attorney-client privilege can be maintained in the legal unit’s files.
Agency response status:
Pending
Recommendation 11
To ensure that the bureau of investigations refers cases for potential criminal prosecution whenever warranted, Cal/OSHA should, by July 2026, do the following:
- Establish written policies or procedures for how the bureau reviews cases, decides whether to investigate them, and decides whether to refer them for prosecution. The guidelines should require that the bureau document a rationale for why it has decided not to investigate or not to refer each case.
- Establish a routine or automated process for the bureau to receive information about accident cases with non-fatal injuries so that it can review them in accordance with requirements in state law.
Agency response status:
Pending
Recommendation 12
To increase its staffing levels and ensure that it can adequately protect workers, DIR should document and implement a plan for requesting additional authorized positions as needed and reducing vacancy rates within Cal/OSHA’s enforcement branch to 20 percent or less by July 2027. The plan should aim to do the following, at minimum:
- Use the 2024 workload study results and the results of our audit to ensure that Cal/OSHA has requested the number of authorized positions necessary to adequately enforce workplace health and safety standards.
- Address key barriers to filling authorized positions and retaining staff, such as by implementing its planned centralized system for managing the hiring process, building career pipelines for safety engineers and industrial hygienists through outreach or other efforts, and making efforts to reduce pay disparities for key positions.
Agency response status:
Pending
Recommendation 13
To modernize its policies and procedures, Cal/OSHA should, by July 2026, take the following actions:
- Formalize a process for reviewing and updating its policies and procedures at least every three years, including any standard forms or templates that its policies require. The process for reviews should include requesting and incorporating feedback from enforcement personnel at district offices.
- Ensure that policies are easily accessible to staff. For example, Cal/OSHA should consider establishing a more user-friendly, searchable manual of its policies if doing so would be helpful for enforcement personnel.
Agency response status:
Pending
Recommendation 14
To ensure that enforcement personnel implement its policies correctly and consistently in practice, Cal/OSHA should work with DIR’s internal audit team to develop a policy or process for conducting recurring audits that examine enforcement branch case files. The policy or process should specify that the audits evaluate whether case files contain at least the following elements, and the first audit should be completed by July 2026:
- Clear rationales for decisions not to inspect complaints and accidents.
- Detailed analyses of employers’ IIPPs, a sufficient number and type of employee interviews, appropriate recordings or notes from those interviews, and complete analyses in violation worksheets for each violation identified.
- Supporting evidence that employers have abated each violation.
- Clear rationales for initial fine classifications and adjustment factors and for post-citation fine reductions.
Agency response status:
Pending
Recommendation 15
To more consistently, accurately, and efficiently perform its work, Cal/OSHA should, by July 2027, develop and implement an electronic case management system that allows it to maintain and manage case files digitally rather than in hard copy. Cal/OSHA should consider developing the system in such a manner that it alerts personnel to any missing documents before allowing personnel to close each case in the system.
Agency response status:
Pending
Recommendation 16
To make it easier for workers to submit complaints, Cal/OSHA should, by January 2027, develop and implement a tool or portal that allows complainants to submit complaints online directly to Cal/OSHA.
Agency response status:
Pending
Recommendation 17
To ensure that it conducts as many proactive inspections as are feasible, Cal/OSHA should, by July 2026, do the following:
- Consider whether consolidating proactive inspection responsibilities within specialized offices such as the high hazard unit—as opposed to also requiring traditional district offices to conduct them—would increase efficiency and effectiveness for these inspections.
- Specify proactive inspection goals for each type of proactive inspection that enforcement personnel conduct. For example, Cal/OSHA could establish goals for each type of proactive inspection and work with enforcement offices to ensure the goals are reasonable given the offices’ staffing and workloads.
- Document a process or methodology for how enforcement personnel should select which employers or worksites to proactively inspect. For example, Cal/OSHA could create and regularly update a list or database of potential proactive inspections to conduct that is ordered by priority and accessible to enforcement personnel.
Agency response status:
Pending
