COVID-19 After Action Report — California Governor's Office of Emergency Services (August 2025)
- Date
- 2023-02-23
Summary
The COVID-19 After Action Report of the California Governor's Office of Emergency Services (Cal OES), dated August 2025, with Nancy Ward as Director and Gavin Newsom as Governor. The report reviews the state's pandemic response to identify strengths, areas for improvement and recommendations, and states that by February 2023 California had 11,105,535 confirmed cases. Its eight chapters cover response structure and coordination, guidance and policies, communications, medical and health services, logistics, social services and economic relief, correctional facilities, and education, followed by appendices including a corrective action plan. The methodology section reports an online survey, 83 interviews and 19 group hotwashes, with Constant Associates contracted to write the report. It closes with corrective action plan entries on school task forces and school testing.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Cite this document
“COVID-19 After Action Report — California Governor's Office of Emergency Services (August 2025).”
Original at www.caloes.ca.gov, dated 2023-02-23. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/2023-02-23-covid-19-after-action-report/
, SHA-256 5d283d6589095b413df73120a9d0dd878b4ba3abea18c904208508860ec3eaa2.Full text
1
CALIFORNIA GOVERNOR’S
OFFICE OF EMERGENCY SERVICES
COVID-19 AFTER ACTION REPORT
AUGUST 2025
Nancy Ward 1
Gavin Newsom Director
Governor
COVID-19 After Action Report
Executive Summary
EXECUTIVE SUMMARY
The COVID-19 pandemic was a catastrophic event that claimed the lives of millions and
fundamentally altered daily life worldwide. California stood at the forefront, confronting
some of the first COVID-19 cases in the United States. As the novel virus spread,
hospitalizations strained the healthcare system and the evolving symptoms fueled fear
and uncertainty. Daily activities became unsafe and resulting shutdowns disrupted
communities. Healthcare professionals, responders, and other essential workers put
themselves at risk to maintain care and critical services. The pandemic’s medical, social,
and economic impacts disproportionately affected older adults, individuals with access
and functional needs (AFN), and people from historically excluded groups. By February
2023, COVID-19 had resulted in 11,105,535 confirmed cases in California and tragically
claimed the lives of over 100,000. 1
The state launched the largest and longest emergency response in its history to combat
the crisis. The California Governor’s Office of Emergency Services (Cal OES) conducted
this After Action Report (AAR) to pinpoint strengths, areas for improvement, and
recommendations for future disasters. The AAR offers a broad view of the state’s
response, complementing the detailed medical and health findings in AARs from the
California Department of Public Health (CDPH) and Emergency Medical Services
Authority (EMSA). The AAR team engaged with over 350 state and local response
officials through surveys, interviews, and focus groups. This report reflects the state’s
commitment to continuous improvement, enhancing its capacity to protect
Californians during future crises. The findings might also provide valuable insight for other
states and jurisdictions preparing for future disasters.
The AAR outlines critical findings concerning the state’s response structure and
coordination, guidance and policies, communications, medical and health services,
logistics, social services and economic relief, correctional facilities, and education.
Consistent themes emerged across these critical areas:
• California’s “unity of effort” approach unified state-level decision-making and
response structures.
• Early and decisive statewide action propelled protective measures and
logistics.
1CDPH. “COVID-19 Updates for February 23," February 23, 2023. Accessed December 5, 2024.
https://www.cdph.ca.gov/Programs/OPA/Pages/NR23-012.aspx.
I
COVID-19 After Action Report
Executive Summary
• Insights and data from scientific experts steered the state's approach
throughout the response, enabling more nuanced and targeted actions over
time.
• California’s disaster response experience enabled leaders to quickly solve
complex problems and mobilize resources.
• Collaboration among California’s state agencies, local governments, non-
governmental organizations (NGOs), and private sector partners launched
innovative solutions.
• The statewide impacts necessitated a top-down decision-making approach
that diverged from typical responses and complicated coordination with local
agencies; the lessons learned can guide future responses to catastrophic
incidents.
• The variable impacts of pandemics require a continual focus on equity in
future planning, mitigation, response, and recovery efforts.
II
COVID-19 After Action Report
Table of Contents
TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................................................... I
INTRODUCTION......................................................................................................................... 1
Unity of effort ........................................................................................................................ 1
Methodology........................................................................................................................ 2
INCIDENT OVERVIEW................................................................................................................ 4
Overview of the COVID-19 Pandemic ............................................................................... 4
Challenges in the United States ......................................................................................... 5
COVID-19 in the State of California ................................................................................... 6
Impacts ................................................................................................................................ 7
TIMELINE .................................................................................................................................... 9
CHAPTER 1: RESPONSE STRUCTURE AND COORDINATION .................................................. 13
Chapter Introduction ......................................................................................................... 13
State Response Structure and Coordination Priorities ................................................. 14
Findings ............................................................................................................................... 14
1.1 State Response Structure .......................................................................................... 15
1.2 Statewide Coordination ............................................................................................ 22
CHAPTER 2: STATE GUIDANCE AND POLICIES ...................................................................... 34
Chapter Introduction ......................................................................................................... 34
State Guidance and Policy Priorities ............................................................................. 35
Findings ............................................................................................................................... 36
2.1 Policy Decision-Making ............................................................................................. 36
2.2 Equity and Inclusion ................................................................................................... 43
CHAPTER 3: COMMUNICATIONS........................................................................................... 46
Chapter Introduction ......................................................................................................... 46
State Communication Priorities ...................................................................................... 47
III
COVID-19 After Action Report
Table of Contents
Findings ............................................................................................................................... 48
3.1 Coordinated Messaging ........................................................................................... 48
3.2 Whole Community Public Messaging ...................................................................... 52
CHAPTER 4: MEDICAL AND HEALTH SERVICES...................................................................... 59
Chapter Introduction ......................................................................................................... 59
State Medical and Health Priorities ................................................................................ 60
Findings ............................................................................................................................... 61
4.1 Testing .......................................................................................................................... 61
4.2 Contact Tracing ......................................................................................................... 66
4.3 Medical Coordination ............................................................................................... 70
4.4 Vaccinations ............................................................................................................... 80
4.5 Mass Fatality Management ...................................................................................... 89
CHAPTER 5: LOGISTICS........................................................................................................... 92
Chapter Introduction ......................................................................................................... 92
State Logistics Priorities..................................................................................................... 93
Findings ............................................................................................................................... 94
5.1 Resource Procurement .............................................................................................. 94
5.2 Resource and Donations Management ............................................................... 101
CHAPTER 6: SOCIAL SERVICES AND ECONOMIC RELIEF ................................................... 105
Chapter Introduction ....................................................................................................... 105
State Social Services and Economic Relief Priorities .................................................. 105
Findings ............................................................................................................................. 107
6.1 Economic Relief........................................................................................................ 107
6.2 Non-Congregate Sheltering Operations ............................................................... 112
6.3 Feeding Operations ................................................................................................. 116
CHAPTER 7: CORRECTIONAL FACILITIES ............................................................................. 121
IV
COVID-19 After Action Report
Table of Contents
Chapter Introduction ....................................................................................................... 121
State Correctional Facilities Priorities ........................................................................... 121
Findings ............................................................................................................................. 122
7.1 Coordination............................................................................................................. 122
7.2 Safety Measures ....................................................................................................... 128
7.3 Inmate Release ........................................................................................................ 134
CHAPTER 8: EDUCATION ...................................................................................................... 137
Chapter Introduction ....................................................................................................... 137
State Education Priorities ............................................................................................... 138
Findings ............................................................................................................................. 138
8.1 Educational Coordination ...................................................................................... 138
8.2 Health and Safety Measures................................................................................... 142
APPENDIX A: ACRONYMS ................................................................................................... 149
APPENDIX B: REFERENCES .................................................................................................... 151
APPENDIX C: EXECUTIVE ORDERS ISSUED BY THE GOVERNOR’S OFFICE .......................... 165
APPENDIX D: CORRECTIVE ACTION PLAN .......................................................................... 177
V
COVID-19 After Action Report
Introduction
INTRODUCTION
The COVID-19 pandemic required an unprecedented state response. Drawing on its
experience from past disasters, the state adapted to a rapidly spreading statewide
threat. Scientists continually advanced their understanding of the virus, adapting to its
mutations and evolving characteristics. The state upheld a commitment to inclusive,
evidence-based decision-making guided by available data. This AAR critically
examines the state’s response, providing actionable insights to strengthen future
operations.
The report encompasses strengths, areas for improvement, and actionable
recommendations across the following areas:
• Response Structure and Coordination
• State Guidance and Policies
• Communications
• Medical and Health Services
• Logistics
• Social Services and Economic Relief
• Correctional Facilities
• Education
UNITY OF EFFORT
The State of California recognizes the unwavering resilience of our communities
throughout the COVID-19 pandemic. This disaster profoundly affected the lives and
livelihoods of Californians. Concurrent emergencies, including wildfires, extreme heat,
floods, and civil unrest, intensified these challenges, necessitating personal and
community sacrifices to curb the disease's spread. Californians leveraged their diversity
to strengthen communities, inspire innovation, and set national and global standards.
The state also commends all state personnel for their relentless and continuing
commitment to the response. State personnel served the public while balancing the
pandemic’s impacts on their own lives, such as caring for children at home from school,
working long hours, protecting their families’ health, and mourning the loss of loved
ones.
The COVID-19 response required profound commitment from the whole community to
unite as one team. Individuals from all sectors came together to support the community,
including emergency management and public health workers, healthcare
1
COVID-19 After Action Report
Introduction
organizations, local and tribal partners, social service agencies, faith-based groups,
businesses, schools, academic institutions, and volunteers. Amidst uncertainty,
challenges, and long hours, the dedication of all involved in California’s unified response
remains immeasurable. Each partner has played a crucial role in protecting all
Californians, meeting the needs of those at increased risk, and collaborating with the
state to mitigate the spread of COVID-19.
METHODOLOGY
The AAR team conducted a comprehensive data collection process to capture insights
from emergency response partners. The state contracted Constant Associates to lead
the development and writing of this report. The team engaged key individuals and
groups through an online survey, 83 interviews, and 19 group hotwashes. They reviewed
over 450 relevant documents, including state plans, COVID-19 data collected during
the response, Standard Operating Procedures, Incident Action Plans, situation reports,
and open-source data.
Response partners across California participated in data collection efforts, representing
state agencies, county and local governments, tribal entities, educational institutions,
and the private sector. A total of 142 stakeholders responded to the survey, 225
individuals participated in hotwash events, and vital personnel from 30 agencies and
partner organizations contributed through individual and small group interviews.
Participating groups included:
• The Office of the Governor
• California Business, Consumer Services, and Housing Agency (BCSH)
• California Department of Alcoholic Beverage Control (ABC)
• California Department of Corrections and Rehabilitation (CDCR)
• California Department of Education (CDE)
• California Department of General Services (DGS)
• California Department of Industrial Relations (DIR)
• California Department of Public Health (CDPH)
• California Department of Social Services (CDSS)
• California Department of State Hospitals (DSH)
• California Emergency Medical Services Authority (EMSA)
• California Government Operations Agency (GovOps)
• California Governor’s Office of Emergency Services (Cal OES)
• California Health and Human Services Agency (CalHHS)
• California Military Department
• University of California Office of the President
2
COVID-19 After Action Report
Introduction
• Local government officials
• School districts across the state
To strengthen the report's inclusivity of all relevant perspectives from response partners,
several individuals who held multiple roles participated in multiple hotwashes and
interviews.
3
COVID-19 After Action Report
Incident Overview
INCIDENT OVERVIEW
OVERVIEW OF THE COVID-19 PANDEMIC
In December 2019, health officials in Wuhan, a metropolitan city in China’s Hubei
Province, identified patients with pneumonia of unknown cause. Symptoms included
fever, dry cough, and respiratory issues. As cases clustered, the World Health
Organization (WHO) investigated and confirmed the existence of a novel coronavirus
named SARS-CoV-2, now known as COVID-19. China implemented public health
measures to contain the virus, but community spread emerged in neighboring countries.
On January 30, 2020, WHO declared a Public Health Emergency of International
Concern, and by March 11, it declared COVID-19 a global pandemic with sustained
human-to-human transmission in 114 countries. Over three years, there were more than
756 million confirmed cases of COVID-19 worldwide, with the highest incidence in the
United States, China, and India. 2
COVID-19 presented global challenges and disrupted daily life worldwide. The novel
virus's rapid spread made it difficult to provide definitive guidance. Public health
recommendations, such as mask-wearing, physical distancing, and isolation, evolved
as more data became available. The virus’s ability to spread asymptomatically or pre-
symptomatically contributed to high transmission rates. Early in the pandemic, an
absence of widespread testing capabilities in the United States further enabled the
virus’s spread. Public health systems, initially ill-equipped to manage a sustained
response, adopted multidisciplinary approaches to address these challenges over time.
Lockdowns and restrictions disrupted business operations, leading to surging
unemployment rates and financial instability for individuals in many industries.
Governments implemented stimulus packages and economic relief measures, but the
scale of the crisis strained economies. Supply chains experienced widespread
disruptions, causing shortages of essential goods. The tourism and hospitality industries
faced unprecedented declines due to travel restrictions and safety concerns.
Education systems also experienced significant challenges, including widespread
school closures and a rapid shift to remote learning. The pandemic revealed and
intensified existing socio-economic inequalities, disproportionately affecting
communities already facing systemic barriers. While some industries adapted to remote
work and digital transformations, others struggled to recover. The pandemic’s socio-
2 WHO. “Timeline of WHO’s Response to COVID-19.” January 29, 2021. Accessed December 9, 2024.
https://www.who.int/news-room/detail/29-06-2020-covidtimeline.
4
COVID-19 After Action Report
Incident Overview
economic impacts shaped global dynamics throughout the duration of the crisis and
for years afterward.
CHALLENGES IN THE UNITED STATES
The COVID-19 pandemic significantly impacted the United States, beginning with the
first laboratory-confirmed case in Washington State on January 20, 2020. This event
prompted the activation of the Centers for Disease Control and Prevention’s (CDC)
Emergency Operations Center (EOC). Federal agencies, including the U.S. Department
of Health and Human Services (USDHHS) and the U.S. Department of Homeland Security
(USDHS), launched response efforts but struggled to quickly address the emergency.
Soon, the pandemic overwhelmed healthcare systems, causing widespread illness and
death while disrupting the economy, leading to millions of job losses and business
closures. Social and political tensions over policies such as mask mandates and
gathering restrictions further complicated response efforts.
Healthcare systems experienced severe strain due to global shortages of personal
protective equipment (PPE), ventilators, and cleaning supplies. By April 2020, 90% of PPE
supplies in the Strategic National Stockpile (SNS) were depleted, and ventilator
shortages in hard-hit areas like California underscored the challenge of acquiring critical
resources. 3 Early efforts to expand COVID-19 testing encountered significant obstacles,
including supply chain limitations, insufficient infrastructure, and evolving U.S. Food and
Drug Administration (FDA) approval thresholds. These obstacles delayed widespread
testing, hindered case identification, and weakened public confidence. As testing
capacity improved by mid-2020, it became a cornerstone of public health strategies,
providing essential data to guide mitigation measures.
The rollout of COVID-19 vaccines in early 2021 marked a turning point in the response,
though equitable distribution and vaccine hesitancy remained significant challenges.
By February 2023, 81% of Americans had received at least one vaccine dose. 4 The U.S.
had recorded over 102 million confirmed cases and more than one million deaths, and
administered more than 670 million vaccine doses. 5 Public health strategies, including
vaccination, expanded testing, physical distancing, mask-wearing, enhanced
ventilation, and hygiene practices, continued to mitigate the spread of COVID-19 and
protect public health.
3 USDHHS, OIG. “The Strategic National Stockpile was not Positioned to Respond Effectively to the COVID-19
Pandemic.” October 2023. Accessed December 9, 2024. https://oig.hhs.gov/oas/reports/region4/42002028.pdf.
4 CDC. “COVID Data Tracker.” February 16, 2023. Accessed December 9, 2024. https://covid.cdc.gov/covid-data-
tracker/#cases_totaldeaths.
5 CDC. “COVID Data Tracker.” February 16, 2023. Accessed December 9, 2024. https://covid.cdc.gov/covid-data-
tracker/#cases_totaldeaths.
5
COVID-19 After Action Report
Incident Overview
COVID-19 IN THE STATE OF CALIFORNIA
California was one of the first states to identify COVID-19 cases. Orange County
confirmed the first case on January 26, 2020, followed by Los Angeles County the next
day. Santa Clara County declared California’s first local health emergency on February
3, 2020. On March 4, 2020, the Governor’s Office declared a State of Emergency and
elevated the State Operations Center (SOC) to its highest level of activation, granting
broader authority to address the crisis. 6
State agencies collaborated to implement and communicate life-saving measures,
emphasizing unified messaging on protective actions. California rapidly increased
COVID-19 testing, becoming a national leader in testing capacity. 7 Guided by science
and data-driven decisions, the state provided consistent and clear information delivery
to the public. State health officials promoted mask-wearing, social distancing, and
hygiene, which were crucial in guiding Californians through pandemic challenges.
In December 2020, California received its first COVID-19 vaccine shipments. State and
local agencies collaborated to establish vaccination sites, including the nation’s first
state-operated mass vaccination sites. On June 15, 2021, the state lifted distancing and
capacity restrictions. 8 By the end of June, large-scale vaccination sites closed, shifting
efforts toward targeted outreach for underserved communities.
Over the next two years, the state responded to variant surges by adjusting guidance
to protect the population. By August 2021, California had vaccinated 80% of its
population. On February 28, 2023, the Governor’s Office officially ended the State of
Emergency, concluding pandemic-related programs, regulations, and mandates. 9
6 UCG Briefing Report. March 1, 2020.
7 Office of the Governor. “Governor Newsom Announces New $2.7 Billion COVID-19 Emergency Response
Package.” January 8, 2022. Accessed December 9, 2024. https://www.gov.ca.gov/2022/01/08/governor-newsom-
announces-new-2-7-billion-covid-19-emergency-response-package/.
8 Office of the Governor. “Governor Newsom Announces Plans to Lift Pandemic Executive Orders as California Fully
Reopens." June 11, 2021. Accessed December 9, 2024. https://www.gov.ca.gov/2021/06/11/as-california-fully-
reopens-governor-newsom-announces-plans-to-lift-pandemic-executive-orders/.
9 Office of the Governor. “Governor Newsome Marks End of California’s COVID-19 State of Emergency.” February
28, 2023. Accessed December 9, 2024. https://www.gov.ca.gov/2023/02/28/governor-newsom-marks-end-of-
californias-covid-19-state-of-emergency/.
6
COVID-19 After Action Report
Incident Overview
Impacts
As of February 2023, California had confirmed 11,105,535 COVID-19 cases and lost over
100,000 lives to the disease. 10 Communities already facing systemic inequities
experienced heightened impacts, including an 11% higher death rate among Latinos,
an 83% higher rate among Pacific Islanders, and a 20% higher rate among Black
Californians. Those earning below $40,000 faced a 15% higher likelihood of infection. 11
Individuals with pre-existing health conditions, negative social determinants of health
such as food insecurity, housing instability, or lack of health insurance, and limited
access to paid leave or worker protections faced disproportionate impacts from
COVID-19. 12
The state experienced significant economic impacts due to COVID-19. Over 2.5 million
Californians lost their jobs during the pandemic. Many local and small businesses
experienced financial hardships, especially within the service and hospitality industries.
By mid-2020, over 61,000 businesses closed. 13 Federal and state funding provided crucial
support, alleviating some of the worst economic impacts. Despite the job market
recovery, small businesses and workers faced lingering consequences.
The pandemic caused widespread and long-lasting societal impacts. The loss of loved
ones forever changed families, and children faced significant learning loss, particularly
in economically disadvantaged communities. Permanent business closures forced
transitions in jobs and careers. Mental health effects gradually emerged among
healthcare workers, first responders, and the broader community. Californians
continued to navigate the pandemic's implications, underscoring its lasting societal
impacts.
The pandemic response required collaborative approaches and the formation of many
new and improved partnerships that could be leveraged for future emergencies. The
state reviewed, maintained, and strengthened processes and plans while investing in
new capabilities with jurisdictional partners.
10 CDPH. “COVID-19 Updates for February 23," February 23, 2023. Accessed December 5, 2024.
https://www.cdph.ca.gov/Programs/OPA/Pages/NR23-012.aspx.
11 State of California. “California for All, California’s Commitment to Health Equity.” November 10, 2022. Accessed
July 2023. https://covid19.ca.gov/equity/#community-impact.
12 State of California. “California for All, California’s Commitment to Health Equity.” November 10, 2022. Accessed
July 2023. https://covid19.ca.gov/equity/#community-impact.
13 Bohn, Sarah. “How Did California’s Economy Recover from COVID – What Comes Next?” March 9, 2022.
Accessed December 9, 2024. https://www.ppic.org/blog/how-did-californias-economy-recover-from-covid-and-
what-comes-next/.
7
COVID-19 After Action Report
Incident Overview
The state embodied Cal OES’s mission, “We protect lives and
We protect lives property, build capabilities, and support our communities for a
and property, build resilient California,” by continuing to serve its residents through
capabilities, and ongoing response efforts. 14 It collaborated with local, state, tribal,
support our
and federal partners to address evolving challenges. The state’s
communities for a
resilient California.
dynamic and flexible response stood out as a model for
interdisciplinary collaboration, demonstrating the importance of
adaptability and partnership in crisis management.
14 State of California Green Buildings. “California Office of Emergency Services, Building and Infrastructure
Resilience.” N.d. Accessed December 9, 2024. https://www.green.ca.gov/buildings/department/CAL%20OES.
8
COVID-19 After Action Report
Timeline
TIMELINE
JANUARY 2020
28 The State Operations Center activated
at Level 3 to coordinate California's
response.
29 Repatriation flights carrying U.S. citizens
from affected areas arrived in
California. MARCH 2020
31 The U.S. Department of Health and 4 The Governor’s Office declared a
Human Services declared a Public State of Emergency.
Health Emergency. 9 The Grand Princess cruise ship
docked at the Port of Oakland to
disembark passengers.
12 California activated its first Alternate
APRIL 2020 Care Site in San Carlos to address
1 The governor announced the closure healthcare surge capacity.
of public schools for the remainder of 13 The Trump Administration declared a
the school year. nationwide emergency.
3 The state launched Project Roomkey 19 The Governor’s Office issued a
to provide safe isolation for statewide Stay at Home Order to
individuals experiencing reduce transmission.
homelessness. 22 The governor requested and
4 The state introduced the COVID-19 received approval for a Presidential
supplies website to streamline access Major Disaster Declaration.
to critical resources.
12 California, Oregon, and Washington
announced the Western States Pact
to coordinate reopening and COVID-
19 control. Colorado and Nevada
later joined.
24 The Governor’s Office announced MAY 2020
the Great Plates Delivered Program. 22 The state launched the California
Connected contact tracing program
and public awareness campaign to
reduce transmission.
9
COVID-19 After Action Report
Timeline
JULY 2020
16 The Governor’s Office announced
Project Homekey, the next phase of
Project Roomkey, to protect AUGUST 2020
Californians experiencing 30 The Governor's Office implemented
homelessness. the Blueprint for a Safer Economy to
reduce COVID-19 statewide, setting
OCTOBER 2020 criteria for adjusting activity
restrictions.
19 The Governor’s Office convened the
Western States Scientific Safety
Review Workgroup to independently
review the safety and efficacy of
COVID-19 vaccines approved by the NOVEMBER 2020
FDA. 30 The Governor’s Office announced
immediate assistance for businesses
impacted by COVID-19, including
DECEMBER 2020 temporary tax relief and $500 million
14 The Governor’s Office launched the in grants.
Vaccinate All 58 campaign for
equitable vaccine distribution as the
first vaccines arrived. Concurrently,
the Western States Scientific Safety
Review Workgroup recommended
the Pfizer-BioNTech vaccine for public
use.
30 The Governor’s Office unveiled
California's Safe Schools for All Plan, JANUARY 2021
aiming to facilitate the safe return to
25 The state launched My Turn, an
in-person instruction.
online platform enabling residents to
check vaccine eligibility and
schedule appointments.
FEBRUARY 2021
16 The state opened mass vaccination
sites at the Oakland Coliseum and
California State University, Los
Angeles.
10
COVID-19 After Action Report
Timeline
MARCH 2021
15 The state introduced the COVID-19
APRIL 2021 Rent Relief Program to support
income-eligible renters and
1 The state received the Johnson & landlords affected by the
Johnson COVID-19 vaccine as it pandemic.
expanded vaccine eligibility to
individuals aged 50 and over.
15 The state expanded COVID-19
vaccine eligibility to all individuals
aged 16 and older.
16 The Governor signed legislation to
support workers displaced by the
pandemic.
26 The state sent COVID-19 supplies to MAY 2021
India to assist in combating severe 9 The state expanded COVID-19
outbreaks. vaccine eligibility to individuals
aged 12 to 15.
14 The Governor’s Office unveiled the
$100 billion California Comeback
JUNE 2021 Plan, the largest economic recovery
15 The Governor’s Office lifted the Stay at package in the state's history, aimed
Home Order and retired the county at addressing key challenges and
tier system, fully reopening California's providing immediate relief.
economy.
22 The state sent additional COVID-19
Supplies to South Asian Countries.
JULY 2021
OCTOBER 2021 9 The Great Plates Delivered program
ended.
1 California became the first state to
announce plans to add the COVID-
19 vaccine to the list of required
vaccinations for in-person school
attendance.
8 The Governor signed a COVID-19
recovery package under the
California Comeback Plan to
provide targeted support for small
businesses.
11
COVID-19 After Action Report
Timeline
OCTOBER 2021
29 The FDA expanded COVID-19
vaccine eligibility to all individuals
aged 5-11
JANUARY 2022
7 The governor activated the
California National Guard to expand
COVID-19 testing statewide.
8 The Governor’s Office announced a
$2.7 billion package to enhance
testing, vaccinations, and support FEBRUARY 2022
for schools and workers.
17 The Governor’s Office introduced
the SMARTER Plan, outlining
California's strategy for managing
COVID-19 with an emphasis on
equity, preparedness, and flexibility.
MARCH 2022
21 Cal OES provided 200,000 COVID-19
testing kits to support high-risk
communities.
26 The state delivered 14.3 million
COVID-19 tests to schools for students
and staff returning from spring break.
AUGUST 2022
25 The state distributed 13.5 million
COVID-19 test kits and pieces of
personal protective equipment to
schools.
DECEMBER 2022
22 The state expanded access to at-
home COVID-19 test kits for K-12
public school students returning from FEBRUARY 2023
winter break. 28 The Governor’s Office terminated
California's COVID-19 State of
Emergency, concluding the
statewide emergency response.
12
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
CHAPTER 1: RESPONSE STRUCTURE
AND COORDINATION
CHAPTER INTRODUCTION
California recognized early that COVID-19 would have statewide impacts requiring an
immediate and unified response. As the virus spread rapidly across borders, local
resource needs surpassed the capacity of individual jurisdictions. Competition for
scarce resources strained mutual aid systems, while concurrent disasters like wildfires
further exacerbated operational and resource challenges. The state enacted executive
orders and guidance to ensure consistency across counties, mitigate virus transmission,
and prioritize areas with the greatest need.
The state centralized decision-making by operating from the SOC for over two years.
Under the governor’s authority, the Cal OES Director led the Unified Coordination Group
(UCG), which included state secretaries, agency leaders, and key partners from the
private sector and community organizations. Co-locating the SOC with the Medical and
Health Coordination Center (MHCC) unified emergency management and public
health responses, combining Cal OES’s coordination authority with public health
expertise. Partnerships with private technology companies enabled SOC staff to
transition to virtual platforms, facilitating real-time information sharing and collaboration.
These tools helped the state track outbreaks, monitor resources, and adjust strategies
based on the latest data.
A science-driven approach guided the state’s response, using the Standardized
Emergency Management System (SEMS) as a structural framework to address evolving
challenges and resource needs. Unlike most disasters led by local jurisdictions, this
pandemic required a state-led, top-down approach. This centralized decision-making
and resource prioritization but presented challenges for local agencies. Regular
coordination calls with local agencies and partners helped enhance coordination over
time. Lessons learned from the COVID-19 pandemic offer valuable insights for future
responses to disasters with statewide impacts.
13
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
State Response Structure and Coordination Priorities
State Response Structure
• Co-located all state government operations at the SOC, including the
Governor’s Office.
• Established the UCG to unify decision-making across state agencies and
partners.
• Used Cal OES’s expanded authorities under the Emergency Services Act (ESA)
to rapidly mobilize resources on an unprecedented scale.
• Integrated the MHCC into the SOC for the first time, improving coordination
between emergency management and public health medical response.
• Leveraged SEMS’ functionality to adapt response operations for statewide
coordination and resource allocation.
• Formed task forces to address and coordinate critical resource needs in
specific mission areas.
Statewide Coordination
• Took early action to manage the repatriation of American citizens exposed to
the virus abroad.
• Supported CDPH and CalHHS in delivering and coordinating public health
efforts.
• Communicated regularly with local governments and state agencies.
• Supported hospital systems and expanded surge capacity.
• Increased testing and contact tracing capabilities.
• Conducted continuity of operations planning at state agencies and
departments.
• Enhanced coordination, capacity, and planning to respond to and recover
from simultaneous events, including COVID-19, wildfires, Public Safety Power
Shutoffs, and other disasters.
FINDINGS
This chapter highlights the state’s successes and lessons learned in establishing its
response structure and coordinating operations. The State Response Structure section
addresses the UCG, integration of state operations at the SOC, and task forces that
managed multi-agency priorities. The Statewide Coordination section examines how
agencies and partners collaborated within this framework to enable efficient
information flow and decision-making.
14
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
1.1 State Response Structure
The state unified emergency management and public health operations early in the
pandemic to address the complexities of COVID-19. The UCG established a centralized
framework for decision-making, policy development, and resource management. The
MHCC integrated with the SOC under Emergency Support Function 8 (ESF-8), fostering
joint operations and collaboration.
This integration streamlined response efforts by consolidating leadership, aligning
strategies, and addressing operational needs. Task forces addressed mission-specific
priorities, enhancing the state’s capacity to adapt to the pandemic’s evolving
demands.
1.1.1 Unified Response Operations
Strength
Strength 1: State leadership quickly recognized that COVID-19 posed a statewide threat
and mobilized unified response operations.
On January 28, 2020, Cal OES activated the SOC to Level 3 and consolidated state
operations. While SEMS typically prioritizes local-level decision-making, state leadership
identified the need for immediate statewide action. Cal OES exercised its authority
under the ESA to coordinate response operations and initiate emergency
procurements. The Governor’s Office issued executive orders to implement unified
medical countermeasures statewide (refer to Chapter 4 for details on the medical
response).
The state established the UCG to streamline decision-
making, coordinate agencies, and define the chain of
command and executive-level span of control. 15 The
UCG is a best practice that began during the Oroville
Dam Spillway Incident in 2017. The group included the
Governor's Office, Directors of other state agencies,
and federal agency officials. Director Ghilarducci
chaired the UCG and served as the principal
Figure 1. UCG coordinating response
coordinator of the state’s response. State Secretaries,
efforts. Source: Cal OES.
Agency Directors, and their designees were assigned
to participate in UCG meetings at the SOC, with an option to dial in remotely. This made
15 Stakeholder Interview
15
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
the SOC a central coordinating point for state operations, aligning state agency leaders
in developing policy and making strategic decisions. 16 The state conducted unified
planning from the SOC, facilitating decision-making and aligning strategies. The state
established 19 multi-agency task forces to provide lines of effort supporting the SOC and
UCG coordinating efforts statewide. 17
The SOC integrated relevant agencies and partners to coordinate response operations
and unify decision-making. The governor relocated his office to the SOC. The state also
integrated the MHCC into the SOC under Emergency Support Function 8 (ESF-8). Key
MHCC sections and CDPH leadership physically relocated to the SOC for the first time.
The MHCC normally operates from CPHD Headquarters located 12 miles away from the
SOC. The strategic decision to integrate emergency management and public health
and medical management promoted streamlined operations and efficient response to
emergent needs.
To align agency strategies and streamline decision-making, the SOC engaged non-
traditional partners, such as the California Department of Human Resources; the
California Department of Insurance; the California Franchise Tax Board; ABC; BCSH;
CalHHS; the California Department of Rehabilitation; CDPH; and CDSS. 18
The state enhanced coordination and resource flow by involving all response partners
in key steps. One key action involved coordinating calls with regional, local, and tribal
government representatives; federal elected officials; AFN community leaders; NGO;
Community Based Organizations (CBOs); and other key stakeholders to involve them in
planning and policy development.
UCG staff developed tools to inform state leaders on state and federal executive orders,
guidance, and response timelines. Those tools included a UCG action tracker
spreadsheet, which consisted of a list of websites on state guidance and policies for
ease of access during the response, and a daily action plan, later expanded to a
briefing report, which provided updates on daily priorities, scheduled meetings, calls,
press conferences, and reporting deadlines. 19
The state held regular meetings with multiple state agencies to ensure cross-disciplinary
coordination, provide subject matter expertise, and share critical situational awareness
updates. This first-of-its-kind effort brought together state agencies to work
16 Stakeholder Hotwash
17 Stakeholder Hotwash
18 Stakeholder Hotwash
19 UCG Action Items Tracker Spreadsheet
16
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
collaboratively on identifying and prioritizing gaps. 20 Those meetings helped the state to
develop appropriate guidance, initiatives, and information for the public, covering
topics such as social distancing, testing, vaccination, PPE and masking, and housing
and social services programs. 21
Areas for Improvement and Recommendations
Area for Improvement 1: Integrating Medical and Health Coordination Center staff into
the State Operations Center required extensive collaboration and training, which posed
a significant learning curve.
The physical and organizational merger of the MHCC into the SOC caused
communication gaps and operational delays. Although both operated under the UCG,
the SOC and MHCC did not consistently share situational reports, leading to conflicting
messages and reinforcing the perception among state staff that the SOC and MHCC
functioned as separate response structures. 22
Disjointed communication affected MHCC staff at the SOC, many of whom lacked
emergency experience and training in SEMS or Incident Command System (ICS). 23
MHCC staff required time to adapt to their roles and bridge communication gaps.
Similarly, emergency management staff needed to familiarize themselves with the
public health system’s structure, including local operations and Medical Health resource
request processes. 24
Leadership meetings gradually incorporated medical and health functions into Incident
Action Plans and the SOC organizational chart. These meetings facilitated the
assignment of MHCC staff to SOC sections, including logistics, operations, and planning.
This integration process required time as emergency managers and MHCC staff aligned
their systems in this complex environment. 25
Recommendation: Establish and operationalize the Medical and Health Coordination
Center in collaboration with Emergency Support Function-8 stakeholders and provide
targeted training for large-scale incidents requiring public health emergency support.
• Develop and implement training modules for MHCC staff on SEMS, ICS, and
SOC operations.
20 Stakeholder Hotwash
21 Stakeholder Interview
22 Stakeholder Interview
23 Stakeholder Interview
24 Stakeholder Interview
25 Stakeholder Interview
17
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
• Conduct cross-training sessions for public health and emergency
management teams to enhance mutual understanding of protocols and
response plans.
• Define operational roles, create public health-focused organizational charts,
and develop tailored Incident Action Plans for medical and health responses.
• Conduct large-scale public health exercises to strengthen MHCC-SOC
integration and foster collaboration with ESF-8 stakeholders.
Area for Improvement 2: Responding to the pandemic required state-level decision-
making that balanced local considerations and coordinated with community
stakeholders.
The pandemic required a coordinated statewide response from the outset. While SEMS
is inherently flexible, this response represented a significant shift from how local agencies
historically interacted with the state. Local agency feedback for this AAR highlighted a
disconnect regarding SEMS application to statewide incidents. By applying lessons
learned from the COVID-19 response, the state can engage local agencies to review
SEMS doctrine and align expectations.
Local officials reported that state guidelines often conflicted with their on-the-ground
experiences, making it difficult to understand the rationale behind state decisions. Local
agencies also struggled to implement state programs as quickly as they were
announced. For example, local governments informed Cal OES Coastal Region staff
that they felt “left out” of coordination and planning led by the Housing and Social
Services Task Force. 26 They perceived state guidance as being “pushed down” to
Operational Areas (OAs) without sufficient engagement or incorporation of OA
perspectives into decision-making. Local agencies shared similar concerns about the
deployment of California National Guard assistance for food banks, the Great Plates
Delivered program, and the distribution of PPE to businesses. 27 The state improved
information flow by conducting regular OA calls and keeping local jurisdictions
updated. Local agencies still often needed to adapt to implement the state’s guidelines
and programs as they were being announced. 28
26 Regional Hotwash
27 Housing and Social Services Task Force. COVID-19 AAR Questionnaire
28 Stakeholder Interview
18
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
Recommendation: Codify lessons learned from the COVID-19 pandemic into
emergency planning, Standardized Emergency Management System doctrine, and
training to prepare for future statewide responses.
• Engage local governments and community partners in planning statewide
responses to better incorporate local perspectives and manage expectations
for communication and operations.
• Update SEMS doctrine and training to highlight its adaptability and codify
COVID-19 lessons learned for future statewide responses.
1.1.2 Task Forces
Strength
Strength 2: The state established 19 task forces to coordinate complex multi-agency
efforts in key areas of the response.
The scale of the COVID-19 response required the UCG and SOC to delegate operations
and decision-making. To engage stakeholders, the state established a larger, more
formal structure to address priorities typically managed by individual agencies. Some
task forces focused on operations, while others developed policy recommendations. By
bringing together diverse perspectives, the task forces improved coordination and
allowed state leaders to manage and track priorities effectively. The table below details
the timeline and mission areas associated with each task force.
Table 1: Task Forces and Missions
Task Force Established Mission
Communications/Crisis March 2020 Ensured stakeholders received accessible,
Communications timely, and accurate information through
internal reporting and informed the public via
coordinated messaging from the Joint
Information Center (JIC)
Corrections Facilities March 2020 Mitigated and reduced COVID-19 exposures in
and Hospitals all the CDCR program areas
Cybersecurity March 2020 Maintained network reliability and security
among state agencies
Economic March 2020 Leveraged federal programs to assist businesses
Impact/Recovery and individuals suffering economic losses
COVID-19 March 2020 Coordinated strategic, targeted enforcement
Enforcement actions and public education opportunities for
businesses and entities that were out of
compliance with public health orders
19
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
Future Opportunities March 2020 Identified opportunities for longer-term
improvements in key areas, including climate
change, social policy, housing, and future work
opportunities for the residents of California
Housing and Social March 2020 Monitored social service programs, guided
Services local agencies, and addressed resource gaps
to support people more vulnerable to infection,
complications, or other impacts
Innovation and March 2020 Configured data, predictive modeling, and
Technology website development for state agencies
Logistics and March 2020 Secured state property and sourced PPE
Commodity internationally to support response operations
Movement throughout the state
Public Health and March 2020 Ensured continuity of public health operations
Medical throughout the state
Schools March 2020 Monitored the ever-changing COVID-19
situation and assessed impacts on the
statewide education system
Transportation and March 2020 Monitored the status of the 16 National Critical
Critical Infrastructure Infrastructure Sectors and reduced the depth
and duration of adverse COVID-19 impacts
across the state
Volunteer and March 2020 Coordinated volunteer and donation
Donations management among the private and non-
profit sectors
Workforce March 2020 Connected residents displaced due to COVID-
Development and 19 with in-demand jobs in essential services and
Surge Capacity private sectors to meet increased needs.
Testing May 2020 Coordinated statewide testing and lab
capacity
Central Valley July 2020 Coordinated with CBOs to mitigate healthcare
impacts and prevent the spread of COVID-19 in
the Central Valley region, with a primary focus
on farm workers and the distribution of
communications in languages other than
English
Imperial August Aligned cross-sector operations among task
2020 forces and coordinated with Mexico to support
the COVID-19 response in Imperial County
20
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
Healthcare Surge August Addressed and mitigated the COVID-19 case
2020 surge that threatened to overwhelm
healthcare facilities throughout the state
Vaccine September Coordinated statewide vaccine administration
2020
Areas for Improvement and Recommendations
Area for Improvement 3: The introduction of task forces caused confusion and
communication problems within the Incident Command System structure, disrupting
roles, information sharing, and situational awareness.
The state's initial implementation of the task forces created confusion about their
relationship to the overall ICS structure. At first, staff from the task forces, SOC, and
Emergency Support Functions (CA-ESF) were unfamiliar with their roles and
responsibilities in a joint task force/SOC environment. 29 Task forces commonly included
positions like “Chair” and "Secretary," which ICS does not define. 30
The direct communication between the task forces and the UCG disrupted situational
awareness and information sharing among SOC and field staff. Agency executives were
members of the UCG and chaired task forces. They often issued directives to task force
staff and reported directly to the UCG, bypassing the Operations Section in the SOC.
Consequently, SOC staff struggled to gather real-time situational updates from task
forces to address field staff inquiries.
Over time, the task force members and SOC staff developed expertise in their roles and
established a clear structure, which contributed to improved coordination.
Recommendation: Standardize Task Force roles within the Incident Command System
structure of the State Operations Center.
• Develop job action sheets for task force positions aligning with ICS terminology,
guidelines, and organizational charts.
• Provide training modules for pre-established task force representatives, SOC,
and UCG staff to support task force integration within the ICS and SEMS
framework.
• Establish clear reporting procedures for task forces through the Operations
Section within the SOC.
• Activate task forces during regular exercises.
29 HSD-STAC – CIP, ART, STRAT. COVID-19 AAR Questionnaire Responses
30 HSD-STAC – CIP, ART, STRAT. COVID-19 AAR Questionnaire Responses
21
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
Area for Improvement 4: The limited number of coordinators for the 19 task forces
hindered information flow, resulting in overlapping responsibilities.
With just two coordinators overseeing 19 task forces, state agencies and task force
coordinators often duplicated efforts. For example, the Schools Task Force and CDE
independently developed policies and procedures on school safety. 31 Similarly,
inadequate coordination between task force coordinators and the Cal OES Office of
Access and Functional Needs (OAFN) staff at times restricted their capacity to integrate
AFN considerations into planning, policy, and response efforts. 32
Recommendation: Expand Task Force Coordinators' resources to establish an
appropriate span of control.
• Assess the workload and responsibilities of each task force to allocate the
appropriate number of coordinators and manage the span of control.
• Develop job action sheets for task force coordinators aligning with ICS
terminology, guidelines, and organizational charts.
• Adopt a plan or procedure to include collaboration mechanisms, such as
regular meetings and information-sharing platforms, between task force
coordination and relevant state responders, including OAFN.
• Exercise information sharing and coordination plans and procedures for
operationalizing future response efforts.
1.2 Statewide Coordination
The state coordinated public health, emergency management, and operational
priorities to address evolving pandemic challenges. Early in the response, it co-located
the SOC and MHCC to centralize operations and unify systems. Task forces addressed
key mission areas, including logistics, public health, and social services. Communication
efforts were supported by the Joint Information Center (JIC), which centralized
messaging and provided updates to stakeholders and the public. These efforts helped
the state align resources and implement strategies to address the pandemic and
concurrent disasters.
31 Live Edit Sessions
32 Live Edit Sessions
22
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
1.2.2 Initial Response Coordination
Strengths
Strength 1: The state coordinated with federal and private sector partners to repatriate,
transport, and quarantine over 4,262 U.S. citizens traveling abroad.
On January 25, 2020, the federal government prepared to repatriate 808 U.S. citizens
from Hubei Province, China, with 195 going to March Air Reserve Base in Riverside
County. Initially, the passengers agreed to a voluntary 72-hour stay in special housing at
the military base. On January 31, 2020, the CDC used USDHHS authority to issue 14-day
federal quarantine orders for repatriated passengers. The March Air Reserve Base
provided secure facilities and infrastructure to isolate and quarantine repatriated
individuals. The state coordinated response efforts and allocated agency resources,
such as mobilizing existing relationships among local governments, health departments,
and emergency services to coordinate civilian ambulance and healthcare support for
the base quarantine facilities. 33
On February 17, 2020, a U.S. government charter plane carrying 437 U.S. passengers from
the Diamond Princess cruise ship, which previously docked in Yokohama, Japan, landed
at Travis Air Force Base to begin a 14-day quarantine. On March 9, 2020, the state
coordinated the release of these passengers using buses to San Francisco International
Airport and Sacramento International Airport. 34
On February 21, the Grand Princess cruise ship set sail for a round trip from San Francisco
to Mexico with a planned return on March 7, 2020. However, on March 4, 2020, Placer
County public health officials announced the COVID-19-related death of an elderly
resident who had tested positive after traveling on the Grand Princess from February 11
to 21. 35 This marked the first COVID-19 death in the state. 36 On March 4, the state
facilitated the transport of the CDC response team to the Grand Princess cruise ship to
collect specimens from 45 symptomatic passengers and crew members. 37 These
33 Stakeholder Interview
34 Travis Air Force Base. “Travis AFB continued support to HHS, Grand Princess Repatriation.” March 10, 2020.
Accessed December 9, 2024. https://www.travis.af.mil/News/Article/2107527/travis-afb-continued-support-to-hhs-
grand-princess-repatriation/.
35 Placer County. “Placer County announces death of patient with COVID-19.” March 4, 2020. Accessed
December 9, 2024. https://www.placer.ca.gov/6438/Death-of-patient-with-COVID-19.
36 Placer County. “Placer County announces death of patient with COVID-19.” March 4, 2020. Accessed
December 9, 2024. https://www.placer.ca.gov/6438/Death-of-patient-with-COVID-19.
37 CDC. “Public Health Responses to COVID-19 Outbreaks on Cruise Ships – Worldwide, February-March 2020.”
March 27, 2020. Accessed December 9, 2024. https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e3.htm.
23
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
specialists tested individuals before they were allowed onshore. 38 The state, in
collaboration with multiple agencies, then safely disembarked and quarantined the
passengers and crew of the Grand Princess ship. On March 7, 2020, the Grand Princess
was rerouted to dock in Oakland on the following day with 21 confirmed COVID-19
cases among its approximately 3,500 passengers and crew. 39 Upon arrival, passengers
and crew were transferred to the Travis Air Force Base for a 14-day quarantine period or
isolation. Cal OES Maritime collaborated closely with the Port of Oakland, the U.S. Coast
Guard, Princess Cruise Lines, and other partners to deploy existing resources and fill
resource gaps by locating local services and supplies. 40,41
Strength 2: Locations for the isolation and quarantine of repatriated Americans were
quickly identified.
The state supported federal partners in establishing sites to receive, screen, and provide
care to repatriated Americans returning under quarantine. Within four days of the first
case identified in California, state, federal, and local agencies set up the first quarantine
site at the March Air Reserve Base in Riverside County.
The state and its federal and local partners quickly pivoted to prepare the base for the
passengers’ arrival and quarantine. The first return flight’s original destination was
Ontario International Airport in San Bernardino County. State agencies working on
repatriation efforts established medical receiving stations and quarantine
accommodations within 48 hours. 42 The state also collaborated with San Bernadino
County to activate the Emergency Repatriation Plan and establish the California
Emergency Repatriation Center Organization. The state conducted just-in-time
repatriation training with agencies to prepare for 200 passengers. 43 During the
repatriation flight to the airport, the CDC announced it would divert to March Air
38 CDC. “Public Health Responses to COVID-19 Outbreaks on Cruise Ships – Worldwide, February-March 2020.”
March 27, 2020. Accessed December 9, 2024. https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e3.htm.
39 Travis Air Force Base. “HHS completes federal quarantine efforts for Grand Princess passengers at Travis AFB.” April
1, 2020. Accessed December 9, 2024. https://www.travis.af.mil/News/Article/2134053/hhs-completes-federal-
quarantine-efforts-for-grand-princess-passengers-at-travi/.
40 Cal OES. “Federal and State Partners Protect the Community of Oakland while Supporting the Safe Return of
Passengers from the Grand Princess Cruise Ship.” March 9, 2020. Accessed December 9, 2024.
https://news.caloes.ca.gov/federal-and-state-partners-protect-the-community-of-oakland-while-supporting-the-
safe-return-of-passengers-from-the-grand-princess-cruise-ship/.
41 Cal OES. “COVID-19 AAR Questionnaire 2020 Grand Princess,” May 2020 (est).
42 Steve Scauzillo. “Inland Officials Remember Flight from Coronavirus Epicenter in China One Year Later.” January
28, 2021. Accessed on December 9, 2024. https://www.pe.com/2021/01/28/inland-officials-remember-airlift-from-
coronavirus-epicenter-in-china-one-year-later/.
43 Survey Response
24
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
Reserve Base in Riverside County. 44 Within a week of the first repatriation flight, the state
and its partners established additional quarantine sites at Travis Air Force Base in Solano
County and the Marine Corps Air Station Miramar in San Diego County modeled after
the first site at March Air Reserve Base. These additional sites were hubs for repatriating
cruise ship passengers during February and March 2020.
Areas for Improvement and Recommendations
Area for Improvement 1: The Emergency Repatriation Plan did not address public health
emergency considerations.
On January 25, 2020, the state and the Administration for Children and Families
collaborated to prepare for the arrival of repatriates at Ontario International Airport. The
state activated the Emergency Repatriation Plan and coordinated local response to
identify lodging options, including an airport hangar, convention center, and local
hotels near the airport. On January 27, 2020, the CDC deemed the state’s housing plan
for repatriates inadequate, as the plan did not include pandemic-specific
considerations, such as safely separating contagious populations. 45 Additionally, the
state was unprepared for the level of pushback from local governments in coordinating
lodging efforts and releasing individuals who had completed their quarantine
requirements. On January 28, 2020, USDHHS, in collaboration with the Department of
Defense, decided to move the quarantine location of repatriates from the Ontario
location to the March Air Reserve base. This change led to a staff shortage for
repatriation efforts, as most state personnel did not relocate to the Base. 46
The Plan did not adequately account for the complexity of repatriating citizens from
many countries via cruise ships and airplanes simultaneously, along with the ensuing
isolation and quarantine requirements. 47 The Administration for Children and Families
participated in the state’s 2018 exercise of the Plan, but the exercise did not include
pandemic considerations.
Recommendation: Revise and expand the State Repatriation Plan to include public
health emergency considerations and lessons learned from COVID-19.
• Develop guidance for isolating and quarantining exposed populations while
ensuring access to medical care.
44 USDHHS, Office of Inspector General. “FDA repeatedly adapted emergency use authorization policies to address
the need for COVID-19 testing.” September 21, 2022. Accessed on December 9, 2024.
https://oig.hhs.gov/documents/evaluation/2617/OEI-01-20-00380-Complete%20Report.pdf.
45 Live Edit Session
46 GAO. Report 21-334
47 Live Edit Session
25
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
• Plan contingencies for quarantine site changes, including staff reallocation
and logistics protocols.
• Conduct regular pandemic-focused exercises with the Administration for
Children and Families and other key agencies to validate the updated
repatriation plan.
• Enhance training program modules for state personnel involved in repatriation
efforts, integrating pandemic-specific modules.
Area for Improvement 2: Challenges arose in repatriating citizens due to complexities in
navigating federal and international partners, processes, and guidance.
The state encountered difficulties in identifying, locating, and communicating with
individuals needing repatriation. It faced challenges responding to foreign
governments' travel restrictions and securing alternatives for cruise ships struggling to
dock, refuel, and disembark passengers and crews at ports worldwide. 48
Stakeholders reported coordination challenges with federal partners during planning for
the first cruise ship arrivals. Response partners struggled to determine which agency
should assume the lead role, particularly for international crews and passengers. 49 Ports
in different counties added another layer of complexity, requiring the state to navigate
various policies and procedures specific to each port.
The influx of repatriates strained the state’s healthcare infrastructure. 50 Inconsistent stay
at home orders issued by other states also complicated the transportation of individuals.
Transportation efforts required careful navigation to ensure the safe and orderly return
of citizens while adhering to diverse regional guidelines.
Recommendation: Exercise the revised State Emergency Repatriation Plan in
collaboration with local, state, and federal partners, incorporating scenarios related to
public health emergencies.
• Include foreign consulates, federal agencies, and local partners in repatriation
exercises.
• Review international regulations and processes to identify barriers from past
responses and mitigate future challenges.
48 GAO. Report 21-334
49 Stakeholder Interview
50 Stakeholder Interview
26
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
1.2.3 Coordination Calls
Strength
Strength 3: The state conducted coordination calls with organizations and entities to
engage them in planning and policy development.
Coordination calls brought together participants from various sectors, such as state,
local, and tribal governments, federal elected officials, AFN community leaders, NGOs,
CBOs, and other key stakeholders. These calls facilitated the exchange of diverse
perspectives and provided critical information, enhancing situational awareness. For
example, the state implemented a weekly California AFN leadership coordination call
early in the COVID-19 response. 51 Participants included state departments, local
jurisdictions, CBOs, NGOs, and various associations, focusing on addressing the needs
of people with AFN and those at greater risk from the pandemic. The calls incorporated
closed captioning, sign language interpretation, and other accommodations to
support accessibility.
Cal OES partnered with the California State Association of Counties and the League of
California Cities to expand local government participation. 52 Beginning in April 2020, the
Cal OES Office of Legislative and External Affairs conducted statewide coordination
calls to provide updates to local, state, federal, and tribal elected and non-elected
members and staff on state response and recovery activities. These calls began with
updates from preidentified state agency speakers and representatives from Cal OES
response, recovery, and tribal affairs. Each call concluded with a question-and-answer
session. At the height of the response, the Office of Legislative and External Affairs
facilitated calls with 400–500 participants. They continued until the State of Emergency
ended in February 2023.
Several other state offices conducted coordination calls during the response. The Office
of Tribal Coordination organized weekly Tribal Assistance Coordination Group calls with
tribal nations. The Office of International Affairs held virtual calls with over 100 CBOs
supporting farm workers, immigrants, undocumented individuals, and Mexican
Consulates. EMSA facilitated coordination calls with Cal OES, the Regional Disaster
Medical Health Coordinators and Specialists Program, and local stakeholders
statewide. 53 CDPH conducted regular Coordination Group calls with skilled nursing
facilities (SNFs), hospitals, the Healthcare-Associated Infections Group, and public
51 Stakeholder Hotwash
52 OLEA COVID-19 Narrative
53 Stakeholder Hotwash
27
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
health officers. These meetings provided stakeholders with the latest information and
opportunities to directly engage with experts and agency representatives. 54
Area for Improvement and Recommendations
Area for Improvement 3: Operational Area Coordination Group calls with the State
Operations Center often lacked participation from appropriate state agency personnel
and did not always allow additional Operational Area personnel to attend.
OA Emergency Managers noted the ineffectiveness of coordination calls, often due to
the absence of relevant state agencies or their tendency to announce a program and
then leave the call. Even though call participants were provided a list of state agencies,
these agencies did not consistently attend the calls. In addition, subject matter experts
from OAs and regional Cal OES Emergency Services Coordinators were not always
invited. The local and regional staff that were able to attend often lacked the necessary
expertise to ask pertinent questions within the limited time available.
Recommendation: Develop a plan or procedure for coordination group calls involving
Operational Areas during emergencies.
• Expand speaker representation from state agencies to provide
comprehensive and timely updates during coordination calls.
• Facilitate interactive sessions during calls, allowing for question-and-answer
sessions or open forums to encourage stakeholder engagement.
• Implement a structured communication plan for timely information
dissemination between coordination calls using newsletters, email, or online
portals.
• Establish mechanisms to encourage input and feedback from local and
regional government representatives.
• Invite regional Cal OES Emergency Services Coordinators to attend
coordination calls.
54 CDPH. COVID-19 AAR. October 2022.
28
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
1.2.4 State Employee Coordination
Strength
Strength 4: The state redirected staff to support emergency operations by leveraging the
authorities granted by Government Code, Title 1, Section 3100.
The state urgently required a sizeable workforce to
address the pandemic's widespread impacts. Disaster
Service Workers, designated under California
Government Code Title 1, Section 3100, played an
important role. This Code designates all government
employees as Disaster Service Workers, compelling
their involvement in disaster-related activities as
directed by their superiors or by law. The state
redirected public agency personnel to support Figure 2. U.S. Forest Service employee
working at the Oakland Coliseum
contact tracing, testing, vaccination, food banks, and vaccination site. Source: Cal OES.
roles in EOCs and Department Operations Centers
(DOCs). The program's flexibility in deploying workers to critical areas during personnel
shortages supported the continuity of essential operations.
Areas for Improvement and Recommendations
Area for Improvement 4: State staff often received contradictory workplace safety
guidance from agencies.
State staff often encountered conflicting workplace safety guidance, requiring later
clarification by the UCG. Initial workplace guidance from California Division of
Occupational Safety and Health (Cal/OSHA) and CDPH on COVID-19 protections
contradicted one another, and Cal/OSHA’s recommendations for using contaminated
N95 respirators conflicted with FDA and CDC guidelines. 55, 56 These inconsistencies
caused confusion and conflict among staff and were reported across all response
levels, from state agencies to local jurisdictions. 57 Staff struggled to maintain trust and
confidence among partners and communities, particularly when partner feedback was
not incorporated into state decisions. 58
55 Stakeholder Interview
56 Task Force AAR
57 Stakeholder Hotwash
58 Stakeholder Interview
29
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
Recommendation: Unify workplace safety guidance across state agencies.
• Establish a centralized task force or workgroup involving Cal/OSHA, CDPH, and
other stakeholders to create consistent workplace safety guidance.
• Align state guidance with federal updates, including FDA and CDC standards,
to prevent contradictions.
• Implement centralized approval and dissemination mechanisms through the
JIC to ensure clear communication for both internal and external audiences.
Area for Improvement 5: The absence of formal Incident Command System training for
inexperienced staff hindered operational flow at the State Operations Center level.
Although the SOC adopted an ICS organizational structure, many personnel lacked
formal ICS training. State agencies redirected staff to support response operations,
including SOC roles, but some representatives lacked SEMS and ICS training or SOC
onboarding. This inexperience disrupted communication channels, leading to improper
information flow and resource request challenges.
Due to high staff turnover and the urgency to fill vacancies, Emergency Hires (E-Hires)
underwent a less intensive screening and interview process. As a result, some E-Hires
began working without a comprehensive understanding of emergency management
principles. Many were less effective in their roles because of misaligned skills and
responsibilities, resulting from limited or no screening. 59 E-hires were limited to 60 days,
with a later executive order increasing the period to 180 days. 60 With most E-Hires also
requiring on-the-job training, the SOC staff was heavily impacted by having to
continually train new E-Hires even with the extended period. 61 Integrating E-Hires earlier
would have enabled proper training and support for the temporary staff. As
acknowledged by one stakeholder, "We did not bring in limited-term staff early enough,
and it was a lesson learned.”
Recommendation: Develop comprehensive training and a structured onboarding
process for all personnel involved in emergency response roles.
• Establish a statewide policy requiring all new hires involved in emergency
response roles, including E-hires, to complete certain SEMS and IS (100, 200,
700, and 800) courses.
• Implement standardized Just-In-Time Training (JITT) for SOC roles, with clear
communication and reporting protocols.
59 Stakeholder Interview
60 Stakeholder Interview
61 Stakeholder Interview and Hotwash
30
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
• Enhance screening and hiring processes to align candidates’ skills with
response needs.
• Integrate limited-term staff early on in response to facilitate proper training and
support for temporary staff.
Area for Improvement 6: Staff attrition in state agencies was driven by long workdays,
response conditions, and high retirement rates leading to an understaffed workforce.
Prolonged workdays and extended response efforts led to staff attrition and retirements,
leaving the state’s response understaffed and reducing institutional knowledge.
Agencies like CDCR and CDPH’s Center for Health Care Quality experienced high
retirement rates, creating vacancies that were challenging to fill. 62 The overwhelmed
state hiring system struggled to keep pace with vacancies. One stakeholder observed
that even under ideal conditions, it would take 60-90 days for someone to start. Cal OES
had a 21% vacancy rate. 63
With the state workforce understaffed, the remaining staff needed mental health
support to cope with stress and burnout. 64 In the SOC, staff became fatigued after
multiple years of working extended shifts for long periods of time. 65 State staff also
struggled with the concern of potential virus exposure at work and fear that they would
expose family members. 66 To counteract this stress and concern, Cal OES enacted strict
safety protocols, brought in comfort animals on several occasions, and stood up an EAP
booth for staff.
Recommendation: Implement measures that support employee well-being and
streamline Human Resources emergency hiring processes.
• Reform and expedite hiring procedures to reduce vacancy rates in critical
agencies, aiming for faster recruitment and onboarding timelines.
• Expand mental health support programs for state responders, offering access
to counseling and stress management resources.
• Introduce flexible work policies to accommodate staff needs, promoting work-
life balance and reducing stress levels.
• Implement structured staff rotation schedules and mandatory rest periods to
prevent burnout and fatigue.
62 CDPH. COVID-19 AAR and CalPROTECT Report
63 Stakeholder Interview
64 Stakeholder Interview
65 Stakeholder Interview
66 Stakeholder Interview
31
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
• Establish succession planning to retain institutional knowledge amid high
retirement rates.
1.2.5 Just-in-Time Training
Strength
Strength 5: Cal OES California Specialized Training Institute transitioned its training to
virtual platforms, establishing Just-in-Time Training that strengthened Emergency
Operations Center staffing and reached over 34,000 responders.
While quarantines and isolation were reducing staffing levels in state DOCs and local
EOCs and DOCs, two pressing factors drove the need to fill EOC positions. 67 The
widespread occurrence of the virus caused substantial personnel shortages. Also,
government measures, such as the stay at home order and physical distancing
guidelines, intensified staffing challenges. The lack of necessary infrastructure and
expertise to operate a virtual EOC only added to the difficulties, leaving EOCs
understaffed.
To further support the surge in demand, California
Specialized Training Institute (CSTI) organized JITT in-
person and virtual sessions. In 2020, CSTI transitioned its
emergency management course from classroom-led
instruction into a Virtual Instructor-led Training
environment, reaching over 34,000 responders. 68 This
transition enabled local responders to continue
operating without jeopardizing their health. Another
example occurred when the SOC established JITT Figure 3. CSTI logo. Source: CSTI website.
through CSTI to address issues with SEMS and ICS familiarity among inexperienced staff.
JITT training provided a structured pathway for training to fill the vacant EOC positions,
ensuring that EOC operations remained resilient and effective. 69
The CSTI’s EOC Position Credentialing Program contributed to strengthening local EOC
staffing across the state by providing a standardized path for individuals to qualify for
specific roles within the EOC. 70 Temporary and other agency staff lacking previous
67 Live Edit Session
68 Cal OES. “Type III EOC Position Credentialing Standards.” January 2022. Accessed on December 9, 2024.
https://www.caloes.ca.gov/wp-content/uploads/Type-III-Task-Book-v3-revision1-2022.pdf.
69 Live Edit Session
70 Cal OES. “Type III EOC Position Credentialing Standards.” January 2022. Accessed on December 9, 2024.
https://www.caloes.ca.gov/wp-content/uploads/Type-III-Task-Book-v3-revision1-2022.pdf.
32
COVID-19 After Action Report
Chapter 1: Response Structure and Coordination
emergency management experience encountered a steep learning curve, and
concurrent disasters further strained available response staff and capabilities. The
program provided staff qualifications and certifications to enhance the local EOC and
DOC response capabilities to ease the strain and meet SEMS/National Incident
Management System requirements. CSTI ramped up its credentialing course delivery to
meet the increased demand. During the training, staff were trained in SEMS, Emergency
Management Mutual Aid, and Emergency Management Assistance Compact.
33
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
CHAPTER 2: STATE GUIDANCE AND
POLICIES
CHAPTER INTRODUCTION
Government agencies acted decisively to curb the spread of COVID-19 and
coordinate a statewide response. The ESA expanded the governor’s authority to enact
policy decisions during the declared disaster and enhanced Cal OES’ role in
coordinating the response and mobilizing resources. State and local health officials
exercised their expanded authority to issue public health orders and take emergency
actions during the crisis. 71 The state implemented lockdowns, travel restrictions, and
safety protocols as mitigation measures. Public health and emergency management
leaders worked closely in the UCG, fostering greater coordination in policy decisions.
State officials relied on scientific experts and projections from the California
Communicable Diseases Assessment Tool (CalCAT) to guide policy decisions.
Information on the virus and its spread shifted rapidly, especially in the early days of the
pandemic. Staff faced challenges in updating systems and providing policymakers with
the most up-to-date medical data. The state remained committed to using high-quality
data to inform statewide initiatives while customizing approaches to address the distinct
needs of each county. Rising mortality and infection rates prompted the state to adopt
a more uniform and expedited approach to guidance development. Over time, the
state allowed for local adjustments, enabling counties to implement measures aligned
with their unique situations. The state can build on lessons learned from COVID-19 to
tailor policy decisions for local needs during future pandemics.
State officials prioritized equity in their policy decisions, recognizing that pandemics
disproportionately affect minority groups, individuals with lower incomes, people with
AFN, older adults, and those underserved by the healthcare system. The state prioritized
PPE, testing, vaccination, and other medical equipment for people at greater risk of
infection or serious complications. Cal OES played an instrumental role in integrating
AFN considerations into policy decisions.
71 California Health and Safety Code § 101040
34
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
State Guidance and Policy Priorities
State Declaration
• Identified the first confirmed COVID-19 case on January 26, 2020.
• Declared a State of Emergency on March 4, 2020.
Data Modeling and Forecasting
• Established a system to monitor the spread of the virus and medical
countermeasures, track test results, cases, close contacts, and vaccinations.
• Adopted a data and science-driven approach to inform public health
decisions.
• Used data modeling and forecasting to promote healthy hygiene practices,
social distancing, and mask-wearing.
Executive Orders & Guidance
• Issued isolation and quarantine guidance for confirmed cases and close
contacts.
• Promoted health and safety for priority populations through social distancing
and stay at home orders.
• Coordinated across agencies for targeted enforcement of guidance,
executive orders, and nonpharmaceutical interventions.
• Provided accurate, timely, and accessible information concerning testing,
vaccination, and reopening public spaces.
Equity and Inclusion
• Incorporated equity into guidance and policies for testing, PPE, and vaccine
distribution.
• Prioritized high-risk groups for vaccination.
• Implemented protections for Californians at higher risk, including older adults,
frontline workers, people with AFN, individuals experiencing homelessness, and
those in congregate settings.
End of Emergency Declaration
• Issued a proclamation terminating California’s COVID-19 State of Emergency
on February 28, 2023.
35
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
FINDINGS
This section offers an overview of the state's guidance and policies, covering key events.
It delves into the state's data-driven decision making and its commitment to equity and
inclusion to serve all Californians effectively.
2.1 Policy Decision-Making
The rapid escalation and statewide impact of the pandemic required the state to adopt
a centralized decision-making approach. Decisions relied on the latest science and
data, with scientific projections guiding the implementation of guidance and executive
orders for testing, contact tracing, and vaccination. As infection rates and healthcare
system impacts rose, the state issued broader guidance to mitigate statewide spread.
When rates declined, the state tailored guidance to reflect the specific needs of each
county and sector. Adjustments included loosening stay at home orders, adapting
sector-specific guidance, and implementing targeted reopening strategies. The state
adapted guidance based on real-time data. The centralized approach created
disparities in policy implementation across counties, prompting county health officers to
issue supplementary jurisdiction-specific orders. Many local governments felt excluded
from decision-making and planning processes due to this centralization.
2.1.1 Data Modeling and Forecasting
Strength
Strength 1: Data modeling and forecasting shaped key decisions, guidance, and
executive orders during the response.
In March 2020, the state implemented CalCAT to
estimate COVID-19 and influenza metrics. CalCAT
incorporated models from academic partners to
forecast trajectory, including case numbers, fatalities,
and hospitalization rates. CalCAT data supported
comparisons and understanding of pandemic trends.
Data-driven insights from CalCAT informed the state's
Figure 4. Screenshot of CalCAT website.
public health policies and played a foundational role
Source: CalCAT website.
in the decision to issue a statewide stay at home order.
CalCAT provided “nowcasts,” or estimates of cases at a given moment utilizing real-
time data, forecasts, and longer-range scenario models for a variety of COVID-19
36
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
indicators at the state, regional, and county scales. CalCAT’s models evaluated
transmission trends and projected hospital and intensive care unit capacity. This
information, combined with other evidence and policy considerations, informed the
implementation of stay at home orders and statewide mask mandates. 72 The state used
these models to inform procurement strategies and provide critical insights into resource
needs such as PPE. CalCAT's projections were also used to inform reopening strategies
and staffing decisions for schools and businesses.
Employing these modeling tools, the state took a proactive approach that addressed
immediate needs and informed long-term planning. The emphasis on data is a
testament to the state’s commitment to science, precision, and responsiveness,
ensuring the health and safety of its residents. 73
Area for Improvement and Recommendations
Area for Improvement 1: The state faced challenges with its data systems related to
developing and updating public health guidance.
In the pandemic’s initial stages, the state's reliance on older data systems, specifically
the California Immunization Registry (CAIR2) and the California Reportable Disease
Information Exchange (CalREDIE), delayed the processing and dissemination of COVID-
19 data. CAIR2, designed for tracking patient immunization records, and CalREDIE,
responsible for collecting surveillance data, struggled to accommodate the high
volume and complexity of data required for tracking real-time data on COVID-19 test
results, hospitalization rates, and vaccination records. These challenges caused delays
in processing data for decision-making, which affected the state’s ability to provide
timely updates and issue health guidance and executive orders. 74
For example, CalCAT's forecasts occasionally displayed a flattening curve, which
suggested the possibility of easing restrictions. However, this apparent stabilization often
resulted from reporting lags rather than an actual decrease in case numbers. These
challenges impacted the issuance of accurate public health guidelines as the state
made decisions based on preliminary data, then had to quickly revise upon receiving
more current and accurate data. 75
72 White, L.A., McCorvie, R., Crow, D. et al. “Assessing the accuracy of California county level COVID-19
hospitalization forecasts to inform public policy decision making.” BMC Public Health 23 (2023): 782.
https://doi.org/10.1186/s12889-023-15649-0.
73 White, L.A., McCorvie, R., Crow, D. et al. “Assessing the accuracy of California county level COVID-19
hospitalization forecasts to inform public policy decision making.” BMC Public Health 23 (2023): 782.
https://doi.org/10.1186/s12889-023-15649-0.
74 Stakeholder Interview
75 Stakeholder Interview
37
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
Recommendation: Invest in upgrading data system capabilities to handle high volumes
and complex health data.
• Upgrade legacy systems to scalable, cloud-based platforms capable of
integrating diverse data sources.
• Implement data validation protocols to improve the accuracy of new data
systems.
• Provide training to state health officials and data analysts to ensure the
workforce is equipped to handle new systems and make informed decisions
based on the latest data.
2.1.2 Executive Orders
Strength
Strength 2: The state issued 76 executive orders, representing the broadest use of
executive authority in California’s emergency history to drive effective public health
measures, distribute resources, and support high-risk and underserved communities
statewide.
Following the declaration of a State of Emergency under Government Code Section
8625 under the California ESA, the Governor’s Office gained authority to issue executive
orders. The pandemic’s nature necessitated a broad application of the ESA. This legal
framework enabled the Governor’s Office to rapidly respond to the evolving situation.
The governor, with the support of a team of experts and scientists, signed 76 executive
orders throughout the response. The orders addressed a wide range of measures,
including guidance for health and safety, testing, vaccination, schools, state licensed
facilities, renters, homeowners, unhoused, etc.
State agencies, including Cal OES, displayed creativity in resolving and mitigating issues
as they arose. For instance, when a policy or executive order proved effective, the state
often expanded upon it. Conversely, when a new policy or initiative did not work as
intended, the state made quick adaptations to it. According to a stakeholder, problem-
solving commenced immediately once an issue was brought to the UCG, showcasing
the state’s proactive approach in dealing with the pandemic. 76
76 Stakeholder interview
38
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
2.1.3 Guidance
Strengths
Strength 3: The state showed adaptability to evolving scientific insights in its COVID-19
guidance.
To address the rapidly changing pandemic landscape, the state actively issued
guidance rooted in real-time data and the latest scientific findings. For example, early
in the pandemic, the state recommended against widespread public mask use,
consistent with the prevailing scientific understanding. However, as new studies
confirmed that masks effectively reduce virus transmission, the state quickly revised its
guidelines, encouraging universal mask-wearing to protect public health.
The state also continuously adapted its policies on social distancing, school and business
operations, and workplace protocols to align with shifts in transmission rates and
infection patterns across regions. By regularly updating its guidance based on emerging
evidence, the state aimed to mitigate the pandemic’s impact, prevent infections, and
save lives. This data-driven, flexible approach allowed the state to respond proactively
to evolving knowledge about the virus, supporting a more effective and targeted public
health response.
Strength 4: Policies related to non-pharmaceutical interventions were rapidly issued
once they proved effective in reducing transmission rates, in the absence of other
available interventions.
In early 2020, the state issued guidance for non-
pharmaceutical interventions, or non-medical
measures, to mitigate the spread. These policies
included postponing or canceling gatherings of more
than 250 individuals, and for higher-risk groups, limiting
gatherings to no more than ten individuals unless social
distancing was imposed by the host. 77 Despite these
measures, cases continued to increase across the
Figure 5. Social media post from the
California Governor's page on March 19, state. This prompted the Governor’s Office to issue the
2020. Source: California Governor first stay at home order on March 19, 2020. Under the
Facebook.
77 Office of the Governor. “California Public Health Experts: Mass Gatherings Should be Postponed or Canceled
Statewide to Slow the Spread of COVID-19.” March 11, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/03/11/california-public-health-experts-mass-gatherings-should-be-postponed-or-
canceled-statewide-to-slow-the-spread-of-covid-19/.
39
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
order, Californians were advised to stay at home unless they met one or both of the
following conditions:
• They needed to access necessary food, prescriptions, or healthcare services.
• They worked in one of California’s 16 critical infrastructure sectors vital to the
physical or economic security, public health, and safety of California. 78
Stay at home orders and physical distancing were the best-known measures to protect
lives before testing became widely available and treatment protocols were developed.
Area for Improvement and Recommendations
Area for Improvement 2: Contradictory guidance from state agencies led to confusion
and challenges in areas like workplace protections, assisted living facilities, medical
support, and alignment between state and federal guidelines.
At the onset of the response, some state agencies issued contradictory guidance. For
example, Cal/OSHA and the CDPH initially presented contradictory recommendations
regarding COVID-19 workplace protections. Similarly, conflicting CDPH and CDSS
directives on SNFs and assisted living facilities resulted in stakeholder confusion
concerning housing requirements for COVID-19 patients. This created uncertainty in
managing COVID-19 cases within these facilities, made providing adequate medical
support and treatment difficult, and compounded the burden on local emergency
departments. The changing guidance from the CDC also caused a lag in aligning state
and federal guidance.
Recommendation: Coordinate with state agencies to produce consistent guidance,
ensuring uniformity in messaging and requirements.
• Form a working group which includes members of all state agencies involved
in the response and is tasked with developing and producing guidance
reflecting a single unified voice. Ensure this working group can quickly and
efficiently adapt guidance to reflect changing federal guidance or
information.
• Assign a single entity, like the JIC, to review and finalize all agency guidance
documents related to response operations and improve consistency in
messaging and requirements.
78 Office of the Governor. “Governor Gavin Newsom Issues Stay at home Order.” March 19, 2020. Accessed July
2023. https://www.gov.ca.gov/2020/03/19/governor-gavin-newsom-issues-stay at home-order/.
40
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
2.1.4 Centralized Approach
Strength
Strength 5: Response and recovery guidance provided each county with opportunities
to tailor strategies to meet community-specific needs.
The Governor's Office introduced The Blueprint for a
Safer Economy guidance on August 28, 2020,
demonstrating the state's commitment to customizing
county-specific guidance and policies. This framework
established color-coded tiers (Purple, Red, Orange,
and Yellow) based on COVID-19 prevalence and
community spread, setting criteria for loosening or
tightening activity restrictions.
Figure 6. Social media post depicting
Placer County moving into Orange Tier.
CDPH issued the "Plan for Reducing COVID-19 and Source: Placer County Government
Adjusting Permitted Sector Activities to Keep Facebook.
Californians Healthy and Safe” plan, outlining a "Tier Framework" to guide business
reopening in each county. This framework outlined the measures each county must
meet based on indicators of disease burden, testing, and health equity. A health equity
metric took effect on October 6, 2020, allowing counties some flexibility in implementing
health protocols based on transmission levels, vaccination rates, and other local factors.
The California Health Equity Metric helped counties tailor efforts to reduce COVID-19
cases while addressing local needs and impacts.
Area for Improvement and Recommendations
Area for Improvement 3: A centralized approach created challenges in implementing
one-size-fits-all guidance at the local level.
The unprecedented public health threat required rapid decision-making grounded in
the latest data and science. Despite efforts like the California Health Equity Metric, the
state's centralized approach often struggled to address the diverse needs of counties.
This created challenges for local governments in applying policies that aligned with their
specific circumstances. For example, Health Officers in San Diego and Los Angeles
Counties issued more stringent restrictions to address the unique needs of their
populations, illustrating the varying demands across regions.
41
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
Local governments reported feeling excluded from
decision-making under the centralized model, leading
to challenges in implementing policies in California’s
diverse communities. The rapidly evolving nature of
COVID-19 left little time for collaborative workgroup
discussions that could have incorporated county input.
This was particularly evident in policies affecting local
businesses and public spaces. Some rural counties with
Figure 7. Social Media post from the lower infection rates had the capacity to safely keep
CDPH's page on March 1, 2022. businesses and public areas open but were required to
Source: CDPH Facebook.
follow the same restrictions applied to densely
populated urban areas with higher infection rates. 79
The Blueprint for a Safer Economy, introduced months into the response, enabled a
more tailored approach by allowing counties to align restrictions with local infection
rates and resource availability. This system gave counties the flexibility to implement
public health measures suited to their specific needs. For rural counties with lower
infection rates, the Blueprint allowed adjustments to restrictions that minimized
unnecessary economic and social disruption while maintaining public health and
safety.
Recommendation: Develop a procedure to gather real-time feedback from local
jurisdictions on the implementation of statewide policies.
• Hold regular debriefings with local jurisdictions to collect reports on policy
successes and areas for improvement to inform response efforts.
• Improve transparency in decision-making processes by providing detailed
insights into the factors influencing decisions, including data-driven and
scientific considerations.
79 LAO. “An Initial Look at Effects of the COVID-19 Pandemic on Local Government Fiscal Condition.” May 2021.
Accessed December 9, 2024. https://lao.ca.gov/reports/2021/4428/COVID-19-Fiscal-Effects-Local-Gov-051221.pdf
42
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
2.2 Equity and Inclusion
California significantly strengthened its public health response and effectively managed
the pandemic by prioritizing equity and inclusion. By emphasizing accessibility
standards, the state ensured fair and inclusive resource allocations, ranging from testing
sites, vaccination distribution, to financial aid. The state’s response also focused on
“California for All” initiatives, targeting specific goals for housing, health, inclusion, and
access to quality care.
2.2.1 Access and Functional Needs
Strengths
Strength 1: Access and functional needs considerations were incorporated into policies
and initiatives to promote equitable and inclusive resource access.
The state’s OAFN championed the priorities of individuals with AFN. AFN Coordinators in
the UCG and SOC embedded AFN considerations into all operational decisions. The
OAFN maintained a representative on several task forces and actively engaged with
the Governor’s Office and other senior executives. Stakeholders acknowledged the
state's focus on making accessibility a primary objective. 80
Cal OES hosted state AFN Leadership Coordination Calls, bringing together leaders from
state agencies and community partners to discuss AFN considerations and requirements
for response and recovery efforts. These calls were open to the public and provided
direct access to state leadership. For instance, during those coordination calls, Cal OES
Logistics and Operations teams requested support for AFN-specific resources. This
prompted the OAFN’s rapid coordination with the SOC to provide PPE to CBOs serving
AFN populations. Through partnering with CBOs, the state distributed over one billion
units of PPE to the AFN community.
Cal OES incorporated inclusivity and accessibility into policies across the state’s
response. This included adapting stay at home orders to allow individuals with disabilities
to access caregivers and support personnel. The OAFN also focused on making
prevention information accessible in various formats, including sign language, Braille,
and easy-to-read materials. Efforts included making emergency housing and
quarantine facilities accessible for individuals with limited mobility or mental health
needs.
80 Stakeholder Interview
43
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
Cal OES published comprehensive playbooks that focused on pandemic accessibility
considerations. These guides addressed the transportation sector and drive-thru
medical sites, providing detailed strategies for accommodating individuals with AFN.
These guides included tips for vaccinating individuals with AFN and supporting their
relatives.
Cal OES launched initiatives that enhanced testing and vaccine accessibility for
individuals with AFN. Free at-home COVID-19 test kits were distributed to people who
were at higher risk of infection or serious symptoms. Mobile vaccination programs
implemented on-site vaccinations in rural communities and provided home-based
vaccination and testing services.
The state improved the accessibility of COVID-19 health resources by using the My Turn
website and American Sign Language (ASL) interpreters. This helped connect resources
with people who are medically underserved, racial and ethnic minority groups, and
those at higher risk of infection and serious symptoms. As reported by a stakeholder,
“there were a lot of strengths, like employing the use of the My Turn website to make at
least 16 languages for vaccination registration available to the public.” 81
Strength 2: Physical accessibility resources were prioritized at vaccine and testing sites,
ensuring compliance with Americans with Disabilities Act procedures.
Although testing and vaccine sites were often in pop-up locations and outside of
buildings designed in compliance with the Americans with Disabilities Act (ADA), the
state prioritized making these spaces accessible for all. Parking lots and other open
spaces were converted into ADA-compliant vaccine and testing sites. The state
provided manual wheelchairs and a variety of chairs, both with arm rests and others
without, as a consideration for those who may need arm rests to push down and help
themselves stand. Isolation areas were set up for those needing a resting space at sites
or with sensory related considerations. Many sites were climate controlled, and signage
was included to address how to request additional accommodation for those who
needed it. 82
81 Stakeholder Interview
82 Stakeholder Interview
44
COVID-19 After Action Report
Chapter 2: State Guidance and Policies
Area for Improvement and Recommendations
Area for Improvement 1: Californians with disabilities raised concerns about the state's
vaccine distribution plan.
In December 2020, the Governor’s Office announced the state's vaccine distribution
plan, sparking concerns among Californians with disabilities. The plan's focus on age-
based eligibility, rather than individual risk levels, led to concerns among at-risk
populations. Individuals under 65, particularly those with disabilities or chronic health
conditions, were at a significantly higher risk of severe illness compared to some older
adults. 83
The age-based prioritization strategy appeared to overlook the complex needs and
challenges of people with disabilities. For many in this community, the risk of exposure to
COVID-19 was amplified by factors such as the need for in-person caregiving, reliance
on public transportation, and the inability to practice social distancing due to their living
conditions or health requirements. Delayed vaccine access led to prolonged isolation,
disrupted essential services, and heightened anxiety about health and safety for these
individuals. 84
Recommendation: Develop and implement strategies to ensure vaccine distribution
plans account for disability access and equity beyond age-based eligibility criteria.
• Conduct a risk assessment of factors that lead to higher rates of infection,
serious symptoms, or other differential impacts and incorporate into future
medical countermeasure prioritizations.
• Identify strategies for strengthening healthcare access and trust with people
who are medically underserved.
• Engage community partners directly in future pandemic planning, including
people who are medically underserved, racial and ethnic minority groups,
and those at higher risk of infection and serious symptoms.
• Outline tiered/score-based process to enhance the equitable distribution of
vaccines and pharmaceuticals to the public.
83 Stakeholder Interview
84 Stakeholder Interview
45
COVID-19 After Action Report
Chapter 3: Communications
CHAPTER 3: COMMUNICATIONS
CHAPTER INTRODUCTION
Communication emerged as one of the most critical priorities and formidable
challenges during the pandemic. In the early stages, the rapid spread and deadly
impact of COVID-19 fueled widespread fear and uncertainty. Scientists uncovered new
insights about the virus daily, prompting frequent updates to policies and guidance. The
virus’s broad impact required swift state-level decisions and clear communication with
the public. However, misinformation and disinformation, coupled with systemic issues
like disparities in healthcare access for minority populations and people with AFN,
deepened public distrust in government messaging.
The state responded by prioritizing timely, accurate,
and accessible communication for all Californians.
Novel public health strategies delivered culturally
relevant information, while regular press conferences
hosted by the Governor’s Office built public trust and
empowered individuals to make informed health
decisions. These press conferences highlighted the
state’s science-driven decision-making, allowing
Figure 8. Governor Newsom and state
community members to hear directly from leaders. By health officials hold a press conference
collaborating with CBOs, tailoring messages to harder- on March 15, 2020. Source: Office of
to-reach populations, and providing information in Governor.
regionally prevalent languages, the state laid the groundwork for a more inclusive and
effective response. Lessons learned from these efforts will inform future communication
strategies during emergencies.
State officials streamlined communication channels to share critical information, public
health guidance, and real-time updates promptly. The JIC played a central role in
coordinating response activities, disseminating updates, and mobilizing public
engagement. However, the urgency to communicate quickly sometimes resulted in
tradeoffs in coordination before announcements. To address this, state leadership
broadened internal discussions to include more state agencies and local government
representatives. These efforts improved communication strategies and strengthened
the state’s ability to address public concerns during the pandemic.
The state leveraged traditional and digital media to keep Californians informed about
public health developments, safety protocols, and available resources. Collaborations
46
COVID-19 After Action Report
Chapter 3: Communications
with social media platforms like TikTok, Facebook, and Instagram expanded
communication reach, connecting with younger audiences and those without
traditional media access. Diverse methods, including videos, graphics, toolkits,
billboards, and text messages, ensured inclusivity and accessibility, aligning messaging
with Californians’ varying learning styles, languages, and cultural backgrounds.
State Communication Priorities
Coordinated Messaging
• Delivered accessible, timely, and accurate information to stakeholders
through internal reporting and the JIC.
• Created a strategy for consistent and proactive public messaging.
• Maintained and updated the CDPH website content, establishing it as the
state’s primary online information hub.
• Sustained uninterrupted operations of Public Safety Communications
infrastructure.
• Reinforced the state's overall messaging by sharing the Governor’s Office
updates and live streams.
Equitable Public Messaging
• Created multilingual videos and messages in English, Japanese, Korean,
Spanish, and Tagalog.
• Provided ASL interpretation for all videos, press conferences, and livestreams.
Crisis Communications
• Collaborated with telecommunications partners and the Cybersecurity and
Infrastructure Security Agency’s National Coordinating Center for
Communications to align crisis messaging and address critical
communication.
• Monitored the statewide 9-1-1 system and facilitated restoral and reporting
procedures.
Public Health Messaging
• Delivered timely, science-based updates on the virus's spread and impact.
• Encouraged preventive hygiene measures such as handwashing.
• Emphasized social distancing and mask-wearing to reduce virus transmission.
• Announced stay at home orders, providing guidance for essential activities
and businesses.
• Connected the public with resources, including testing, PPE, and vaccines.
• Coordinated efforts with experts to address vaccine hesitancy and
misinformation.
47
COVID-19 After Action Report
Chapter 3: Communications
FINDINGS
This chapter explores the critical role of communication in emergency response,
focusing on coordinated messaging and inclusive public messaging strategies. The
Coordinated Messaging section examines the JIC's operations and information-sharing
protocols, highlighting the importance of unified communication. The Whole
Community Public Messaging section outlines diverse approaches such as press
conferences, social media partnerships, and culturally tailored outreach, emphasizing
the state's inclusive and comprehensive communication efforts.
3.1 Coordinated Messaging
The state’s JIC coordinated communication efforts and functioned as a centralized hub
for managing information during the response. Communications teams synthesized
extensive information from various sources into clear, actionable messages for response
partners and the public. Early in the pandemic, PIOs across the state proactively
directed information flow and coordinated messaging efforts with state agencies and
local jurisdictions. PIOs managed media inquiries and requests while disseminating
critical guidance for the public. Using real-time data, communication staff developed
messages addressing COVID-19’s virulence and mortality rates.
The state expanded its communication reach by leveraging multiple platforms and
engaging diverse stakeholders. Virtual tools streamlined messaging and minimized
delays. Routine conference calls fostered cross-functional coordination and improved
decision-making by engaging experts from various sectors.
The JIC prioritized accessibility by expanding outreach to high-risk populations through
diverse communication strategies. A key initiative included integrating specialized
expertise within the JIC’s framework. This involved adding a certified deaf interpreter
and a disaster response interpreter, who supported communication with people who
are deaf or hard of hearing. These interpreters enhanced accessibility during press
briefings and ensured assistive technology compatibility for website content, setting a
standard for inclusive communication.
The state encountered challenges connecting with local agencies and the public due
to delays in activating the JIC. Early in the response, the lack of a centralized information
repository led to redundant and inconsistent messaging. Rapid changes in virus data
and the urgency to issue guidance often left little time for advance notice to agency
staff, local governments, or community partners.
48
COVID-19 After Action Report
Chapter 3: Communications
3.1.1 Joint Information Center
Strength
Strength 1: The Joint Information Center integrated a certified deaf interpreter and
disaster response interpreter, improving accessibility and establishing inclusive
communication practices for people with access and functional needs.
To facilitate communication with people who are deaf
and hard of hearing, the state incorporated an expert
in deaf culture and ASL into the JIC. 85 This individual
held dual roles as a certified deaf interpreter and
disaster response interpreter. They provided ASL
interpretation at the Governor’s press briefings,
promoted compliance with accessibility standards for
screen readers, and helped to ensure that all website
Figure 9. Press conference with Former
Director Ghilarducci, including ASL content was accessible to individuals who relied on
interpretation. Source: Cal OES. assistive technology. They were also certified through
the state’s Disaster Response Interpreter (DRI) Program,
with specific training in response and recovery activities. 86 Including ASL interpreters in
press briefings established them as a standard practice for agencies statewide. 87 This
commitment to accessibility demonstrates a dedication to serving all Californians and
has set a precedent for future emergency response efforts.
Area for Improvement and Recommendations
Area for Improvement 1: The delayed mobilization of the Joint Information Center at the
pandemic’s onset resulted in redundant messaging.
The state activated the JIC on March 2, 2020, approximately five weeks after identifying
its first COVID-19 case. In the interim, the absence of a centralized hub complicated
coordination and delayed streamlined communication efforts. Managing the influx of
information, parsing relevant insights, and relaying them to partners and the public
proved challenging. Agencies often issued public information independently, resulting
in uncoordinated messaging. Redundant message relay efforts across multiple briefings
diminished communication effectiveness with the public and response partners. 88
85 OAFN. COVID-19 AAR Questionnaire, September 2020
86 Cal OES. “Communication.” N.d. Accessed December 9, 2024. https://www.caloes.ca.gov/office-of-the-
director/policy-administration/access-functional-needs/communication/
87 Stakeholder Questionnaire
88 Stakeholder Interview
49
COVID-19 After Action Report
Chapter 3: Communications
Recommendation: Set a clear threshold for Joint Information Center activation during
an emergency response.
• Determine EOC activation levels that trigger JIC mobilization under the State
Emergency Plan.
• Develop a protocol for scaling JIC operations according to the incident size
and scope, including the need for a virtual JIC and contingency staffing.
• Develop unified protocols for state agencies, including Cal OES and CDPH, to
streamline public messaging.
• Standardize agency information dissemination through centralized
communication platforms.
3.1.2 Information Sharing
Strength
Strength 2: Interagency communication methods evolved during the pandemic,
enabling faster distribution of critical information and resolution of emerging issues.
After addressing initial challenges, responders across all government levels streamlined
information flow through a combination of established and innovative methods.
Coordination calls, virtual meetings, video conferencing tools, and cloud-based
document management systems enhanced communication among healthcare
facilities, law enforcement, health departments, Medical Health Operational Area
Coordinators (MHOACs), and tribal communities. 89 To manage the increasing volume
and complexity of information, the state introduced web-based data dashboards,
providing real-time insights that improved situational awareness and workflow
efficiency.
Daily statewide OA conference calls were a primary method of communication,
providing regular opportunities for stakeholders to report on operational status. Weekly
coordination calls offered a platform for in-depth discussion and collaborative
brainstorming among various state agencies, including CalHHS, CDPH, the California
Department of Rehabilitation, and California Department of Housing and Community
Development. 90 The OAFN regularly hosted meetings to discuss the concerns and
priorities of people with mobility issues, sensory or cognitive impairments, chronic
medical conditions, and other diverse needs. 91 This initiative, designated as the State
Access and Functional Needs Leadership Coordination Call, offered a unique
89 Stakeholder Interview
90 Stakeholder Interview
91 Stakeholder Questionnaire
50
COVID-19 After Action Report
Chapter 3: Communications
opportunity for community leaders and stakeholders to engage in meaningful
discussions about accessibility and inclusion, paving the way for enhanced decision-
making and strategic planning. Coordination calls played a critical role in sharing
guidance and addressing misinformation as policies evolved.
Area for Improvement and Recommendations
Area for Improvement 2: The state's decision to prioritize communication policy and
guidance without lead time to local officials left them unprepared to address public
questions.
The pandemic presented challenges to information sharing between state and local
governments working to implement policy guidance. The novel and evolving nature of
the virus often rendered information obsolete within days of being issued. Public health
officials needed to modify guidance rapidly, leaving little time to connect with local
officials prior to broadcasting the message to the public. These unavoidable shifts in
guidance left local officials without the context needed to communicate policy
decisions to their constituents at times. 92 Local EOC staff often had little knowledge of
press conference announcements, sometimes receiving only a brief notice 30 minutes
prior to public announcements. While regular interagency coordination calls fostered
coordination and situational awareness, inconsistencies in messaging across different
calls led to confusion at the grassroots level. Stakeholders trying to navigate this
information at the local level sometimes received incomplete or contradictory details
about policies or programs.
Despite the state’s best efforts to bring local officials up to speed on information
changes, county and city staff often found themselves working to keep pace with
information released during press conferences from the Governor’s Office. One
example of this challenge was the state’s announcement of the Great Plates Delivered
program. 93 The state's April 2020 announcement of this food delivery program, without
prior notice to jurisdictions, required local agencies to adapt and mobilize resources.
Local governments lacked time to prepare answers to anticipated questions or provide
guidance. As a result, residents felt confused or frustrated with local authorities. 94
Local responders expressed frustration with a perceived lack of coordination on state
agency-run conference calls, which were frequently scheduled to occur simultaneously
or at the close of workdays or work weeks. The urgency to share information and
92 Stakeholder Interview
93 Stakeholder Interview
94 Stakeholder Interview
51
COVID-19 After Action Report
Chapter 3: Communications
operational protocols complicated coordination efforts. Releases often provided
counties little time to prepare or offer feedback before the information became public.
Consequently, local government staff encountered inquiries with scarce information at
their disposal, hindering their ability to provide comprehensive responses.
Recommendation: Create an information prioritization system and notification protocol
to enhance communication with local officials and response partners.
• Prioritize the release of critical life safety information while scheduling less
urgent updates to provide response partners with preparation time. Develop
and distribute concise fact sheets summarizing key points or policy changes.
• Coordinate with state agencies to align regular call schedules, avoiding
overlaps and enhancing participation. Utilize JIC resources to maintain and
share a unified call schedule.
• Establish dedicated feedback channels for partners to share insights on
recently released and upcoming guidance, fostering a collaborative response
framework.
3.2 Whole Community Public Messaging
Communicating with the whole community during a pandemic is key to slowing the
spread of the virus and protecting people most vulnerable to its impacts. State officials
used press conferences, social media, toolkits, and traditional media to keep
Californians informed. Over time, the state expanded its use of translations, accessibility
features, and inclusive tools, significantly broadening the reach and impact of public
health messaging.
3.2.1 Press Conferences
Strength
Strength 1: The Governor’s Office held regular press conferences, which aired live on
local stations and streamed on social media.
Regular press conferences from the Governor’s Office provided guidance and updates
on response initiatives. Early in the response, the Governor’s Office recognized the need
to share real-time and transparent information. 95 The governor’s press conferences
became a reliable method for sharing new or updated information and guidance
quickly. These press conferences delivered direct and consistent communication from
state leadership. The press conferences were initially broadcast on local television
95 RFI Response
52
COVID-19 After Action Report
Chapter 3: Communications
channels and later expanded to live-streaming on popular social media platforms such
as Facebook and YouTube. Broadcasting on social media aimed to reach a wider
audience in combination with traditional media. 96
3.2.2 Social Media Partnerships
Strength
Strength 2: The Governor’s Office and state agencies partnered with social media
companies to launch a public awareness campaign, widely disseminating critical
information, resources, and health guidelines.
Social media was a valuable tool for sharing public
health guidance and combatting misinformation. On
March 29, 2020, the Governor's Office announced a
partnership with leading social media companies to
support the COVID-19 public awareness campaign.
The partnership shared content across digital
platforms, radio, television, and outdoor advertising.
Companies such as Google, Facebook, Instagram, X
Figure 10. Social media post about
(formerly Twitter), TikTok, and Spotify made advertising social distancing. Source: Cal OES
space available to help ensure Californians received Facebook.
critical messages. 97 The campaign provided information about essential resources and
services that remained open in addition to providing guidance on how to stay healthy.
The state used multiple strategies to make information more accessible, including
shareable social media graphics and videos. 98
96 Stakeholder Hotwash
97 Office of the Governor. “California's leading digital and media platforms, businesses, and celebrities’ partner with
the state to amplify covid-19 "stay home. save lives." public awareness campaign.” 2020. Accessed December 9,
2024. https://www.gov.ca.gov/2020/03/29/californias-leading-digital-and-media-platforms-businesses-and-
celebrities-partner-with-the-state-to-amplify-covid-19-stay-home-save-lives-public-awareness-campaign.
98 Office of the Governor. “California's leading digital and media platforms, businesses, and celebrities’ partner with
the state to amplify covid-19 "stay home. save lives." public awareness campaign.” 2020. Accessed December 9,
2024. https://www.gov.ca.gov/2020/03/29/californias-leading-digital-and-media-platforms-businesses-and-
celebrities-partner-with-the-state-to-amplify-covid-19-stay-home-save-lives-public-awareness-campaign.
53
COVID-19 After Action Report
Chapter 3: Communications
3.2.3 Equitable Public Messaging
Strengths
Strength 3: The state provided inclusive guidance through multiple platforms to reach
diverse audiences.
State agencies provided local jurisdictions with
presentations, graphics, toolkits, and other resources
from press conferences and statewide campaigns
to maintain consistent messaging. 99 Local agencies
tailored this information to their jurisdictions while
referencing state-provided materials. The
Communications/Crisis Communications Task Force
supported local PIOs with COVID-19 graphics, public
service announcement toolkits, Listos California
Figure 11. Example of CDPH resources, and Mixteco language resources. The
Communications Toolkit material. task force also facilitated coordination calls, shared
Source: CDPH website.
significant news releases, and amplified testing site
information on social media. 100 In November 2021, Cal OES issued guidance on diverse
marketing and accessible formats to improve vaccination rates for people with AFN,
drawing on lessons learned during mass vaccination efforts. The state later published an
Inclusive Planning Blueprint for Addressing Access and Functional Needs at Mass
Testing/Vaccination Sites. 101
Information was distributed via social media, radio, billboards, commercials, apps,
phone calls, texts, emails, flyers, and newspapers. The multi-channel messaging
approach reached Californians from a wide array of demographic backgrounds and
differing language preferences and abilities. ASL interpreters translated press briefings in
real time, aligning with the state's Whole Community approach to emergency planning
and response. These actions supported direct access to information for diverse
populations, including people with AFN and those with Limited English Proficiency.
99 Stakeholder Interview
100 UCG Briefing Report. August 9, 2020.
101 Cal OES. “Inclusive Planning Blueprint for Addressing Access and Functional Needs at Mass Testing/Vaccination
Sites.” November 2021. Accessed December 9, 2024. https://www.caloes.ca.gov/wp-
content/uploads/AFN/Documents/AFN-Library/Cal-OES-Inclusive-Planning-Blueprint-for-Addressing-AFN-at-Mass-
Vaccination-and-Testing-Sites.pdf.
54
COVID-19 After Action Report
Chapter 3: Communications
Strength 4: Leaders prioritized equitable, accessible communication by sharing up-to-
date scientific information about the virus and establishing a call center to address
public inquiries.
Accessible communication fostered public trust and reached diverse audiences during
the pandemic. The Governor’s Office regularly provided critical updates on COVID-19’s
spread, transmission, morbidity and mortality rates, and available support services. This
information was shared through press releases and a centralized online resource where
Californians could find the latest pandemic updates, public health guidance, testing
and vaccination locations, school safety protocols, public assistance programs, housing
resources, and travel guidelines. To make these resources truly equitable, the state
distributed public information in multiple languages and formats to meet the needs of
California’s diverse communities. 102
To further support equitable access to information, the state established a call center
dedicated to answering public questions and addressing concerns. This call center
played a vital role in reaching Californians without reliable internet access and provided
personalized responses to specific queries. Through this science-driven approach, the
state connected Californians with resources to better understand COVID-19’s nature, its
impacts, and critical measures to prevent its spread, reaching diverse communities
across the state.
Strength 5: Listos California enhanced inclusive communications with people at
increased risk to the pandemic’s impacts through both direct communication and
coordinated efforts among Non-Governmental Organizations, state agencies, and local
partners.
Launched by Cal OES, Listos California is a statewide
campaign that improved emergency preparedness
among the state’s diverse communities, providing
crucial pandemic safety and disaster preparedness
information to millions of Californians who might not
otherwise have access. Introduced in 2019, the
initiative marked the first comprehensive effort aimed
at helping communities at higher risk during disasters,
such as wildfires, earthquakes, floods, and pandemics. Figure 12. Listos California Logo.
Listos California collaborates with NGOs and state Source: Listos Facebook.
agencies to ensure preparedness messages are
shared broadly by trusted representatives. The campaign connects with the community
102CDPH. “COVID-19 Multilingual Resources.” 2023.
55
COVID-19 After Action Report
Chapter 3: Communications
through local CBOs that maintain strong relationships with their neighbors and a deep
understanding of their specific needs and languages.
Within days of the Governor’s Office declaration, Listos California ramped up outreach
efforts and incorporated pandemic-specific information into its materials. It shared
pandemic campaign messages from the Governor’s Office, and adapted them with
webinars, web-based training, and physical delivery of pandemic education materials
to additional populations of socially vulnerable Californians. The campaign partnered
with state agencies to facilitate the distribution of new health resources to populations,
including immigrants, people with disabilities, and individuals experiencing
homelessness. Listos California reached over 16 million Californians with information and
activities related to COVID-19 and its impacts. 103
Strength 6: The state deployed a public communications strategy to promote vaccine
safety, combat misinformation, and encourage equitable vaccination access among
all Californians.
The arrival of COVID-19 vaccines marked a pivotal
moment in the state's pandemic response. The state
prioritized equitable access to vaccine information for
all Californians, regardless of language,
socioeconomic status, or geographic location. In
December 2020, the Governor’s Office launched the
Vaccinate All 58 campaign to facilitate a fair,
organized distribution across the state’s 58 counties. As
part of the Vaccine Task Force, this campaign focused
Figure 13. Vaccinate All 58 Campaign on overcoming community-specific barriers to
Logo. Source: State of California
website. vaccination and provided information in multiple
languages and accessible formats.
The Vaccinate All 58 campaign incorporated strategies to reach communities directly,
addressing misinformation and vaccine hesitancy in ways that respected California’s
diversity. From March 2021 to February 2023, weekly newsletters in English and Spanish
delivered regular updates. The Let’s Get to ImmUnity campaign extended this outreach
with a free, multilingual toolkit that included flyers, social media content, and influencer-
driven messaging on platforms like TikTok, Instagram, and YouTube. 104 By prioritizing
transparency and accessibility, the state connected underserved populations with
103 Listos California. “Listos California Impact Report.” May 2021. https://www.listoscalifornia.org/wp-
content/uploads/2021/06/Listos-California-Impact-Report.pdf.
104 CDPH. “CDPH Launches Let's Get to ImmUnity Campaign to Boost COVID-19 Vaccine Acceptance.” March 17,
2021. Accessed December 9, 2024. https://www.cdph.ca.gov/Programs/OPA/Pages/NR21-091.aspx.
56
COVID-19 After Action Report
Chapter 3: Communications
vaccine resources, achieving a 74.2% full vaccination rate by the end of 2022,
surpassing the national average of 68.9%. 105
Area for Improvement and Recommendations
Area for Improvement 1: The state faced challenges in reaching target audiences with
key messages during the response.
Public health emergencies highlight systemic inequalities in access to healthcare and
information, as well as distrust in government among certain communities. This can
dampen the impact of vital messaging from the government or wider public health
sources. As the response unfolded, the state adapted its communication methods to
better connect with these communities. For example, the Central Valley Task Force
found that television and radio messaging was more effective than printed materials for
certain Spanish-speaking populations in the region. The task force attributed this to lower
literacy rates and a lack of trust in the government.
Communications teams managed heavy workloads to deliver lifesaving information
and adapt to evolving guidance. As a result, information was sometimes incomplete or
hard to understand. For example, Cal OES learned some In-Home Support Service (IHSS)
providers did not show up to assist their clients because they were unclear whether they
were essential employees under the stay at home order. This was later clarified in the
Governor’s Office briefings.
Challenges intensified when federal guidance lacked clarity or required interpretation.
Statewide PIOs struggled to keep up with changes in federal guidance and pandemic
considerations, often having to respond quickly without sufficient time or support. As the
response progressed, the state solidified regular communication with counties and the
public, prioritized equity, and addressed misinformation and disinformation.
Recommendation: Expand targeted communication strategies using diverse media
platforms, community networks, and culturally appropriate outreach to improve
message delivery and audience engagement.
• Engage trusted community organizations during both planning and response
to inform and amplify public messaging to historically underserved
communities.
• Increase engagement with community organizations to disseminate
information to those lacking access to traditional communication forms like
television, radio, and the internet.
105 CDC. “COVID data tracker.” Accessed July 2023. https://covid.cdc.gov/covid-data-tracker
57
COVID-19 After Action Report
Chapter 3: Communications
• Issue messages in accessible, understandable formats, such as holding a press
conference and launching a video campaign with engaging visuals and
simple language to explain new requirements.
58
COVID-19 After Action Report
Chapter 4: Medical and Health Services
CHAPTER 4: MEDICAL AND HEALTH
SERVICES
CHAPTER INTRODUCTION
COVID-19 presented a global medical crisis which placed health professionals at the
forefront of the response, providing care for those infected with COVID-19 and offering
scientific expertise to inform emergency actions and policy decisions. The state
adopted a unified approach early in the pandemic, integrating public health and
emergency management response structures. The state rapidly expanded testing
capacity, implementing programs designed to identify COVID-19 cases, detect
infections early, isolate affected individuals, monitor virus transmission, and guide public
health strategies.
To support the medical and health services response,
the state issued executive orders, policies, and
guidance to adapt regulations and expand
healthcare capacity. For example, the state
temporarily modified regulations, enabling healthcare
facilities to expand capacity while balancing public
safety and healthcare demands. As the pandemic
progressed, the Blueprint for a Safer Economy provided
Figure 14. Social media post aligned to
a tiered system for reopening businesses based on the state’s face covering mandate.
local COVID-19 conditions. CDPH also issued infection Source: California Governor Facebook.
control guidance for healthcare and long-term care
facilities (LTCFs), equipping healthcare professionals with critical directives. These
actions supported the state’s ability to manage the pandemic’s impacts, strengthen
healthcare system resilience, and provide science-based guidance to providers and
the public.
Public health agencies at state and local levels coordinated information campaigns to
educate Californians on preventative measures, testing, and vaccination efforts.
Partnerships with medical and health services across the state enhanced the capacity
to address immediate challenges and established a foundation for a resilient
healthcare system ready to navigate future emergencies.
59
COVID-19 After Action Report
Chapter 4: Medical and Health Services
State Medical and Health Priorities
Early Detection and Surveillance
• Monitored updates from international health organizations such as WHO, CDC,
and USDHHS.
• Confirmed California’s first COVID-19 case on January 26, 2020.
• Established systems to monitor cases and identify potential outbreaks.
• Set up testing sites across the state to facilitate testing for symptomatic
individuals.
Containment and Isolation
• Implemented isolation and quarantine guidance for confirmed cases and
close contacts.
• Partnered with local officials to conduct contact tracing for individuals
exposed to confirmed cases.
• Collaborated with healthcare facilities to isolate and treat severe cases.
• Implemented stay at home orders and expanded access to testing in
vulnerable communities to reduce transmission risks.
Data Modeling and Forecasting
• Used data and scientific insights to guide public health decisions.
• Promoted healthy hygiene practices, social distancing, and face covering
using data modeling and forecasting.
Healthcare System Readiness
• Secured essential medical supplies amidst resource scarcity.
• Expanded hospital capacity by requesting Federal Medical Stations (FMSs)
and creating Alternate Care Sites (ACSs).
• Improved infection control practices and supported LTCFs in strengthening
prevention measures to limit virus spread among residents and staff at higher
risk of severe outcomes.
Community Engagement
• Partnered with local communities to promote preventative measures and
address resource gaps.
• Addressed public concerns and supported those at high risk of infection.
Vaccination Campaign
• Distributed and administered vaccines equitably as they became available.
• Prioritized high-risk groups for vaccination.
60
COVID-19 After Action Report
Chapter 4: Medical and Health Services
FINDINGS
This section examines medical and health services, focusing on testing, contact tracing,
medical coordination, vaccination, and mass fatality management.
4.1 Testing
Reliable and timely COVID-19 testing played a pivotal role in managing the public
health response and protecting high-risk communities. At the onset of the pandemic,
the state faced challenges in scaling up testing efforts due to a national shortage of
federal testing kits and delays in establishing supply chains. 106 Despite these obstacles,
the state rapidly established a sophisticated testing infrastructure to address the needs
of all Californians.
The state leveraged SEMS to coordinate testing resources among local public health
agencies through the Testing Task Force (TTF). The centralized command structure under
SEMS provided logistical support and staffing, reducing bottlenecks and delays at
testing sites. 107 Early challenges provided valuable lessons that improved efficiency and
enabled testing operations to adjust in real time. 108 The state established the TTF to
enhance coordination and allocate testing resources to local communities, which
included representatives from key health organizations and state agencies. This
collaboration improved testing speed and the dissemination of results to individuals. 109
Equity remained a cornerstone of the state’s testing strategy. Early deployment of
mobile testing units provided access to individuals in underserved areas and
communities with limited testing infrastructure. 110 These mobile units significantly
expanded community coverage, reduced disparities in testing availability, and
supported health equity throughout the state.
106 CDPH. “COVID-19 AAR – Testing.” July 2024.
107 Stakeholder Interview
108 Stakeholder Interview
109 CDPH. “COVID-19 AAR – Testing.” July 2024 and Stakeholder Hotwash
110 CDPH. “COVID-19 AAR – Testing.” July 2024 and Stakeholder Interview
61
COVID-19 After Action Report
Chapter 4: Medical and Health Services
4.1.1 Testing Task Force
Strength
Strength 1: The Testing Task Force expanded capacity and addressed scaling
challenges, central to the state’s testing efforts.
The TTF was established in March 2020 by the Governor’s Office, CalHHS, and Cal OES.
The TTF acted quickly to implement widespread testing measures just weeks after the
first cases appeared in the state, working to overcome a lack of existing infrastructure
and limited resources. 111 Despite these challenges, the TTF successfully coordinated with
state agencies and local partners to mobilize over 6,700 testing sites across the state. 112
Their agile response included a strategic shift from solely offering polymerase chain
reaction (PCR) testing to incorporating antigen tests as they became available,
enabling faster and more widespread testing. Throughout the pandemic, the TTF
facilitated the administration of over 14 million PCR tests and distributed 107 million over-
the-counter antigen tests. 113
The TTF held weekly calls and provided a dedicated email address for direct
communication, supporting clear coordination across all testing sites. This fostered
consistent interaction with stakeholders and helped align testing operations. The TTF also
embraced a continuous improvement mindset, adapting testing strategies based on
real-time feedback and making adjustments to meet the evolving demands. 114
Areas for Improvement and Recommendations
Area for Improvement 1: The rapid increase in demand challenged the state's ability to
effectively adapt and operationalize testing resources.
Decades of underfunding left the state’s public health labs primarily functioning as
reference labs with limited capacity for high-volume testing. These labs were not
equipped to manage the rapid scale-up needed during the COVID-19 response, which
exposed deep resource limitations. As testing needs surged, the labs encountered
critical shortages of essential supplies like pipettes, reagents, and plastics, which stalled
lab operations and constrained testing throughput.
111 CDPH. “COVID-19 AAR – Testing.” July 2024.
112 CDPH. “COVID-19 AAR – Testing.” July 2024.
113 CDPH. “COVID-19 AAR – Testing.” July 2024.
114 CDPH. “COVID-19 AAR – Testing.” July 2024 and Stakeholder Hotwash
62
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Test result delays of seven to ten days hindered testing’s effectiveness as a real-time
public health tool. Delayed results impeded case tracking, contact tracing, and timely
isolation, which allowed COVID-19 to spread more freely. The centralized supply chain
struggled to allocate resources efficiently to labs with the greatest need, further slowing
response efforts in heavily impacted areas. 115
Recommendation: Strengthen the state’s public health lab infrastructure and establish
resilient supply chain protocols to enhance testing response capabilities.
• Develop public/private partnerships with commercial labs to quickly
accommodate high-volume testing, to support public health labs maintain
their reference capability.
• Develop a strategic reserve of critical supplies (pipettes, reagents, plastics) to
reduce reliance on external suppliers during surges.
• Establish a prioritized supply chain protocol to quickly allocate resources to the
most impacted labs, improving turnaround times.
• Explore capability building options or funding to expand lab capacity and
ensure readiness for future public health needs.
Area for Improvement 2: Relying on contractors without public health expertise hindered
the Testing Task Force’s operational effectiveness and policy clarity.
To address staffing gaps, the TTF rapidly onboarded contractors from various
organizations who took on critical roles in project and program management, training,
analysis, and reporting. However, due to the urgent demand, the TTF faced challenges
hiring contractors with expertise in public health, laboratory science, and clinical testing.
This led to gaps in the contractors’ understanding of technical public health protocols
and reduced their ability to contribute effectively to high-stakes decision-making
processes. 116
Contractors contributed to program management and reporting but lacked role clarity
in policy discussions. This caused misalignment between TTF staff and contractors, as
some viewed contractors as overly influential in policy decisions, a role traditionally held
by state experts. TTF staff noted confusion stemming from contractors’ limited technical
expertise in managing large-scale testing, particularly for nuanced approaches in
antigen testing. The absence of specialized knowledge among contractors led to
occasional misunderstandings, with some contractors proposing or supporting policies
that did not fully align with TTF’s strategic goals. 117
115 CDPH. “COVID-19 AAR – Testing.” July 2024.
116 CDPH. “COVID-19 AAR – Testing.” July 2024.
117 CDPH. “COVID-19 AAR – Testing.” July 2024.
63
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Recommendation: Develop a clear contract that defines qualifications, roles, and
responsibilities of the contractors. Include structured onboarding and integration
protocols to ensure their expertise aligns with their roles.
• Create guidelines and communication channels to integrate contractors into
policy discussions while avoiding misalignment with state staff.
• Prioritize recruiting contractors with expertise in public health, laboratory
science, or clinical testing to improve contributions to policy discussions and
operational decisions.
• Screen candidates for technical backgrounds that align with high-demand
testing roles to match qualifications with operational needs.
• Create onboarding guidelines and communication channels to define
contractor roles in policy, decision-making, and technical support.
• Develop job action sheets within the ICS framework to define contractor roles
during onboarding.
4.1.2 Testing Sites
Strengths
Strength 2: The California National Guard supported the rapid establishment and
operation of COVID-19 testing sites across the state.
The state experienced a critical staffing shortage during the pandemic due to the
prolonged and overwhelming demands placed on essential services. Despite
reassigning personnel from other state agencies, the shortage persisted, necessitating
the activation of the California National Guard. This enabled the rapid establishment
and operation of over 200 vendor-run and 3,400 state-supported PCR community
testing sites, including 182 locations in non-rural counties and 45 in rural counties.
The California National Guard also supported the deployment of buses and traveling
teams, expanding the state's testing capacity. 118 During the Omicron surge from
December 2021 through January 2022, when staffing shortages became even more
acute, the California National Guard increased testing by an additional 100,000 tests
per week and conducted 298,538 tests. 119
118 CDPH. “COVID-19 AAR – Testing.” July 2024.
119 CDPH. “COVID-19 AAR – Testing.” July 2024 and Stakeholder Email. August 10, 2023.
64
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Strength 3: Innovative solutions and targeted guidance effectively enhanced
accessibility to COVID-19 testing.
In May 2020, the state launched a user-friendly testing website that improved
accessibility by helping residents find nearby testing sites. This website featured an
interactive map and sections like "How to get tested," which empowered residents to
make informed decisions. 120 The TTF developed the California COVID-19 Courier Network
to further expand access. The network added over 110 drop-box locations across the
state and facilitated the transportation of PCR samples from community-based testing
sites. The TTF’s actions improved the timelines of sample delivery, particularly from rural
and underserved areas.
The TTF modified state-run PCR sites to allow walk-up appointments, expanding beyond
drive-through and pre-scheduled options. These modifications directly addressed equity
barriers by providing access for individuals without vehicles or those who encountered
difficulties with digital literacy. For example, walk-up appointments served rural areas
where public transportation was limited and assisted residents with irregular work
schedules who could not pre-schedule appointments. Walk-up sites also allowed
people to access testing without a vehicle or internet access.
The TTF also launched a free At-Home/Over-the-Counter antigen testing program that
distributed over 107 million test kits. This program provided a no-cost testing option for
uninsured, underinsured, and underserved populations. The TTF also integrated
telehealth into its Test-to-Treat initiative, enabling individuals who tested positive to
quickly access COVID-19 therapeutics, which further enhanced both the accessibility
and effectiveness of the testing program. 121
4.1.3 Laboratory Infrastructure
Strength
Strength 4: The Valencia Branch Lab significantly bolstered California's COVID-19 testing
capacity.
State leadership established the Valencia Branch Lab (VBL) under an accelerated
timeline to meet the urgent demand for increased testing. Early challenges with quality
control and testing accuracy were addressed through targeted adjustments. 122
120 Cal OES News. “State Launches California COVID-19 Testing Sites Website.” May 6, 2020, Accessed December 9,
2024.https://news.caloes.ca.gov/state-launches-california-covid-19-testing-sites-website/.
121 CDPH. “COVID-19 AAR – Testing.” July 2024.
122 CDPH. “COVID-19 AAR – Testing.” July 2024.
65
COVID-19 After Action Report
Chapter 4: Medical and Health Services
The VBL processed up to 150,000 PCR diagnostic tests daily, significantly increasing the
state’s testing capacity. By partnering with vendors to secure resources, the lab
addressed earlier supply chain challenges and stabilized the testing material supply. The
VBL also improved testing turnaround times to approximately 48 hours, contributing to
the state’s overall testing efficiency. 123
A public-private partnership expanded the state’s testing capacity by 75% through the
VBL, providing greater operational control. The lab also introduced a technology
platform that improved PCR registration, reporting, and logistics management,
enhancing overall testing efficiency. 124
4.2 Contact Tracing
Contact tracing and case investigation served as vital tools to reduce virus transmission.
The state redirected up to 10,000 employees, trained through the Virtual Training
Academy (VTA), to support local health departments. Contact tracers engaged
individuals who tested positive and their close contacts, ensuring access to testing and
care.
The state collaborated with local health departments, academia, and the private
sector to develop CalCONNECT, a digital tracing system empowering text-based
communication via the CalCONNECT Virtual Assistant. CA Notify, a digital exposure
notification technology formed through collaboration with private firms and academia,
alerted users about potential exposures. These efforts aided in curbing virus transmission
and responding to cases across the state.
4.2.1 California Connected Program
Strengths
Strength 1: Innovative partnerships supported the development and evolution of the
California Connected program, strengthening case investigation and contact tracing
efforts.
On May 22, 2020, the Governor’s Office launched California Connected, the state's
contact tracing program and public awareness campaign. Public health workers
reached individuals who tested positive for COVID-19 and their close contacts,
123 CDPH. “COVID-19 AAR – Testing.” July 2024.
124 CDPH. “COVID-19 AAR – Testing.” July 2024.
66
COVID-19 After Action Report
Chapter 4: Medical and Health Services
connecting them with testing and medical care. 125 The program succeeded through
partnerships among the Governor’s Office, CDPH, local public health departments, and
the University of California campuses in San Francisco and Los Angeles. Together, they
established the VTA, an online platform for training contact tracers and case
investigators.
The state collaborated with Google, Apple, and the
University of California, San Diego, to develop
CalCONNECT, a digital contact tracing technology.
Private consulting firms contributed to creating
technology solutions that supported statewide case
investigation and contact tracing, mobilizing 10,000
contact tracers. 126 Recognizing the critical role of case
investigation, California Connected expanded to
Figure 15. California Connected logo.
Source: California Connected website. include this component.
The technology was designed with local needs in mind,
involving local health departments as end users and co-creators. In July 2020, the state
established a Governance Council and launched an online exchange forum to gather
feedback from local health departments. The Council met twice weekly to support the
development of CalCONNECT through collaboration. 127
In August 2020, CDPH introduced the CalCONNECT Virtual Assistant, a text-based
messaging tool to improve public health communication. Initially, contact tracing relied
on phone calls, but the rising volume of cases created challenges. The Virtual Assistant
sent text alerts about upcoming contact tracer calls and later allowed contacts to
complete a short survey via text, streamlining the process. 128
Refinements continued with input from local health jurisdictions. In April 2021,
CalCONNECT integrated with California’s immunization registry, CAIR2, allowing
contact tracers to view individuals’ vaccination status and prioritize unvaccinated
individuals. This integration marked a significant milestone in improving the state’s public
health response. 129
125 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
126 CDPH.” COVID-19 AAR – Four Chapters”. October 2022.
127 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
128 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
129 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
67
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Strength 2: The state redirected employees to build contact tracing capacity at the local
level.
In April 2020, CDPH reported a need for 31,400 contact tracers, case investigators, and
supervisory and administrative staff statewide. 130 The estimate was based on a survey in
which local health departments projected the number of staff they needed to contact
every person testing positive within their jurisdiction. While more than 10,000 existing local
health department staff were immediately called upon to learn and conduct contact
tracing, an additional workforce was necessary. 131
The following month, the state launched a plan to create a pool of up to 10,000
redirected state employees from various state agencies to supplement local health
department staffing. 132 Leadership from the California Department of Human Resources,
GovOps, and CDPH’s Human Resources Division held multiple meetings to develop a
process for expanding the workforce. All state departments were required to identify 5%
of employees for redirection to the contact tracing program. 133 These staff members
would undergo training at the VTA to become contact tracers and case investigators.
After they had completed the training, CDPH assigned the redirected staff to the local
health departments who had submitted requests through their MHOAC program. CDPH
then virtually deployed the redirected staff to local health departments, where they
conducted remote contact tracing for their counties.
The VTA provided support to over 2,000 state staff redirected from more than 100
different state departments. The redirected state workforce program ended on June
30, 2022, and California Connected teams concluded their work on July 30, 2022. 134
Strength 3: The state partnered with California Universities to virtually train redirected
workers as contact tracers and case investigators.
Redirected state employees had to be trained prior to assisting locals with case
investigation and contact tracing efforts. The VTA consisted of six new courses, many of
them in English and Spanish, along with a skills-based lab component to prepare
redirected state workers for contact tracing. Additionally, the VTA leveraged existing
university resources and professional networks to enhance state workers’ interviewing
skills in small group settings. This included providing state workers with access to
130 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
131 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
132 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
133 Cal HR. “Contact Tracer Assignment Information for State Departments.” May 28, 2020. Accessed December 9,
2024. https://www.calhr.ca.gov/Documents/contact-tracer-assignment-information-for-state-departments.pdf.
134 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
68
COVID-19 After Action Report
Chapter 4: Medical and Health Services
educational platforms and skilled course facilitators. Between the program’s 2020
inception and October 2022, over 11,000 learners completed VTA courses, and almost
30,000 attendees have participated in its continuing education and peer-to-peer
Townhall and Communities of Practice sessions. 135
Strength 4: CA Notify, a digital exposure notification technology, was implemented to
complement California Connected’s contact tracing efforts.
The state launched CA Notify, a cutting-edge contact
tracing solution, in collaboration with private
technology firms and academia. CA Notify was a free
digital exposure notification system offering an opt-in
feature for users to receive notifications if they were
recently within six feet of someone who had tested
positive for COVID-19. As of October 2022, over 17.2
million Californians had activated the technology, and
Figure 16. CA Notify social media post
the tool had sent an estimated 1.23 million exposure encouraging people to sign up for
notifications. 136 exposure notifications. Source: State of
California website.
Area for Improvement and Recommendations
Area for Improvement 1: California Connected program encountered administrative
challenges during its development and operation.
The California Connected program struggled to adequately staff its contact tracing
efforts. The program heavily relied on redirected state workers but lacked crucial
support services in HR, budgetary management, and administration to manage this
workforce. Initial attempts to manage redirected staff using tools like Excel proved
unsuccessful, leading to frustration among workers and their respective departments. It
became clear that establishing program infrastructure before beginning was essential,
emphasizing the crucial need for proper preparation.
The state encountered unforeseen technological difficulties in transitioning redirected
staff to a remote work environment, hindered by a lack of essential technology skills,
remote setup, and familiarity with collaboration tools. There were also not enough
managers for the expanding contact tracing workforce, necessitating state-level
oversight due to restrictions on county-level managers.
135 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
136 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
69
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Recommendation: Develop an infrastructure plan for implementing programs similar to
California Connected.
• Conduct a comprehensive assessment and gap analysis of the infrastructure
needed for the California Connected program, detailing anticipated needs
for supervisors, case investigators, technical specialists, and support staff, with
a focus on scalability.
• Develop a staffing plan to anticipate needs and align with program goals.
• Establish clear guidelines on potential redirections by including criteria for
selecting employees and the process for transitioning them into new roles.
• Identify staffing leads responsible for overseeing the deployment of staffing
strategies and addressing related challenges.
4.3 Medical Coordination
As global competition for scarce medical resources intensified, the state implemented
strategies to address supply chain disruptions and mitigate resource and staffing
shortages. EMSA released emergency reserves of PPE, including N95 masks, to support
healthcare facilities. During the state’s initial surge, medical facilities activated mass
casualty surge strategies to expand patient treatment capacity.
As confirmed cases surged statewide, the state activated ACSs and requested FMSs to
support local medical facilities. FMSs are mobile units equipped with beds, supplies, and
medications to provide care for up to 250 individuals. Due to initial incomplete deliveries,
officials disassembled FMS kits to supplement hospital capacities and meet escalating
medical demands.
To address staffing shortages, the state mobilized the California National Guard and
expanded the pool of available medical professionals. The Governor’s Office issued
Executive Orders to manage medical surges, focusing on maintaining staffing levels
and supplementing health facilities with critical supplies.
4.3.1 Scarce Medical and Health Resources
Strength
Strength 1: The state coordinated the distribution of biomedical equipment and personal
protective equipment to address supply chain challenges.
The pandemic caused a global surge in demand, resulting in critical shortages of
medical supplies. The state prioritized securing resources for healthcare facilities,
essential workers, and critical infrastructure. On April 1, 2020, the governor signed
70
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Executive Order N-41-20, allocating emergency funds for PPE, medical equipment, and
other resources to support surging healthcare demands. 137
Cal OES led logistics operations, leveraging its capacity
and expanded authority under the ESA. The state
quickly distributed biomedical equipment and PPE to
address local shortages and supply chain gaps. On
April 4, 2020, the state launched a one-stop website,
allowing businesses to donate, sell, or manufacture
critical medical supplies, including ventilators, N95
Figure 17. Cal OES warehouse
respirators, and testing materials. 138 These efforts
receiving a shipment of donated PPE. bolstered the state’s supply of essential equipment,
Source: Cal OES. supporting public health and safety.
Cal OES collaborated with CDPH to purchase and store
biomedical equipment, including ventilators, pulse oximeters, N95 masks, face shields,
gowns, and gloves. 139 The Logistics and Commodity Movement Task Force worked with
CDPH's Occupational Health Branch to procure PPE, particularly N95 masks. CDPH
established specifications for state purchases, advised on resource procurement, and
developed PPE guidelines. Cal OES distributed these resources to requesting counties. 140
The CDPH COVID-19 AAR contains more specific information on the procurement and
distribution of PPE for medical surge.
In March 2020, the Logistics and Commodity Movement Task Force devised a statewide
strategy to procure PPE and medical supplies. The strategy established purchasing
goals, which included 500 million N95 masks, 500 million surgical masks, 100 million
surgical gowns, 500 million nitrile gloves, 200 million face shields, and 10 million goggles,
among other items. 141 DGS led the bulk procurement team, which included buyers from
DGS, EMSA, California Department of Forestry and Fire Protection (CAL FIRE), California
Department of Transportation (Caltrans), and CDPH. The state entered into over 200
137 Executive Department, State of California. “Executive Order N-41-20.” April 1, 2020. Accessed July 2023.
https://www.gov.ca.gov/wp-content/uploads/2020/04/4.1.20-EO-N-41-20.pdf.
138 Office of the Governor. “Governor Newsom Launches One-Stop Website for Donations & Sales of Essential
Medical Supplies in Fight Against COVID-19.” April 4, 2020. Accessed December 9,2024.
https://www.gov.ca.gov/2020/04/04/governor-newsom-launches-one-stop-website-for-donations-sales-of-essential-
medical-supplies-in-fight-against-covid-19/.
139 CDPH. “COVID-19 AAR Chapter.”
140 CDPH. “COVID-19 AAR Chapter.”
141 DGS. “2020 Year in Review.” Accessed July 2023. https://www.dgs.ca.gov/-/media/Divisions/DGS/Strategic-
Plan/DGS-2020YearInReview-ADA.pdf?la=en&hash=4B426C8785696CD16D540DA91D7D8B844BC92BE1.
71
COVID-19 After Action Report
Chapter 4: Medical and Health Services
contracts for over $2 billion in goods. 142 On June 8, 2020, the state contracted BYD North
America to produce and ship 150 million N95 masks for distribution to healthcare workers
and those requiring respiratory-style masks. 143 Increased demand for ventilators led to
the establishment of a contract with Meditech to provide ventilators for statewide use.
After the state sent the requested resources to counties, the counties distributed them
to their local partners. 144
Chapter 5: Logistics provides more detailed information on logistics operations and
purchasing goals during the state’s COVID-19 response.
4.3.2 Medical Surge Capacity
Strengths
Strength 2: The state promptly activated Alternate Care Sites when the healthcare
systems’ demands exceeded capacity.
Medical facilities prepared for patient surges by canceling
“This statewide
elective surgeries, discharging stable patients, reducing
implementation of
room occupancy, and repurposing spaces for extra patient ACSs marked a
care. Some facilities used modular tents to augment significant first in the
treatment or triage spaces. 145 state's response efforts,
providing valuable
Cal OES, DGS, CAL FIRE, best practices and
CDPH, and EMSA lessons learned for
collaborated to provide future planning and
logistical support for ACSs, implementation of
designed to care for alternate care
patients needing less services.”
critical care than hospitals - Stakeholder Hotwash
Figure 18. EMSA helped provide logistical
provided. Imperial, Fresno,
support alongside Cal OES, DGS, Cal Fire, Orange, and Sacramento Counties had the highest
and CDPH. Source: EMSA Facebook.
142 DGS. “2020 Year in Review.” Accessed July 2023. https://www.dgs.ca.gov/-/media/Divisions/DGS/Strategic-
Plan/DGS-2020YearInReview-ADA.pdf?la=en&hash=4B426C8785696CD16D540DA91D7D8B844BC92BE1.
143 Office of the Governor. “Governor Newsom Announces Federal Health and Safety Certification of Life-Saving
N95 Maks.” June 8, 2020. Accessed December 9, 2024. https://www.gov.ca.gov/2020/06/08/governor-newsom-
announces-federal-health-and-safety-certification-of-life-saving-n95-masks/.
144 Office of the Governor. “Governor Newsom Announces Federal Health and Safety Certification of Life-Saving
N95 Maks.” June 8, 2020. Accessed December 9, 2024. https://www.gov.ca.gov/2020/06/08/governor-newsom-
announces-federal-health-and-safety-certification-of-life-saving-n95-masks/.
145 Stakeholder Hotwash
72
COVID-19 After Action Report
Chapter 4: Medical and Health Services
participation, with over 1,300 patients. 146 Some ACSs in Riverside and Sacramento
Counties also offered drive-through testing and monoclonal antibody infusions. ACSs
opened during periods of increased demand and remained on standby to meet future
surges.
Further details on ACSs and medical surge operations can be found in the CDPH COVID-
19 AAR 147 and EMSA COVID-19 AAR. 148
Strength 3: Federal medical station supplies expanded hospital capacity during the
response.
The state created portable "field hospitals in a box" by
separating supplies from the FMS and supplementing
them with EMSA resources. These field hospitals were
deployed statewide. 149 DGS assembled a
procurement team to purchase goods and support
ACS and FMS site operations. 150
Figure 19. “Field hospitals in a box”
The FMS included essential medical resources for
palleted supplies staged at the Dixon
warehouse. Source: Cal OES. public health emergencies and disasters, such as
pharmaceuticals, medical instruments, wound care
items, and PPE (e.g., masks, gloves, gowns, and face shields). It also provided medical
equipment, including ventilators, portable oxygen concentrators, defibrillators, infusion
pumps, and diagnostic tools like test kits and reagents. Communication tools, such as
radios and satellite phones, supported coordination among healthcare providers and
emergency responders.
Access to such supplies and the ability to establish the “field hospital in a box” provided
much-needed hospital decompression in early surges when protocols for care were still
unclear. It also allowed for additional space when isolation became a critical
component of patient care.
146 CDPH. “COVID-19 AAR – Medical Surge.” October 2022.
147 CDPH. “COVID-19 AAR – Medical Surge.” October 2022.
148 EMSA. “COVID-19 AAR.”
149 Stakeholder Hotwash
150 Logistics and Commodities Task Force. “After Action Review.” October 12, 2020.
73
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Area for Improvement and Recommendations
Area for Improvement 1: Alternate Care Sites were underutilized due to evolving
pandemic needs, guidelines, and resources.
Evolving pandemic conditions led to challenges in maximizing the utility of ACSs. Patient
needs changed over time, and health resource demands fluctuated. Factors such as
evolving COVID-19 knowledge, treatment guidelines, local case variability, and
healthcare infrastructure impacted ACS utilization. Resource allocation strategies
designed for worst-case scenarios sometimes left ACSs underutilized in less-impacted
counties, even where they could have provided value. Transportation shortages and
insufficiently trained staff hindered patient transfers from hospitals to ACSs. Patients often
preferred hospital care, even when ACSs were available.
Based on Los Angeles County's population, the state requested United States Naval
Ships (USNS) Mercy in anticipation of a surge of thousands of COVID-19 patients in March
and April 2020. While having a capacity of 1,000 beds, USNS Mercy only cared for 77
patients over seven and a half weeks. Integrating medical staff and appropriate
infectious disease protocols into the ship presented challenges. Additionally, a lack of
effective inventory control from warehouse to end-user complicated the distribution of
essential medical supplies and equipment onboard. 151
Standardized equipment and resource shortages in state-provided ACS models
hindered local jurisdictions' ability to plan, set up, and operate the sites. 152 The diversity
in the physical setup, scope of services, and associated costs resulted in unequal access
to health services for Californians across jurisdictions. Some areas struggled to find ACS
locations that met accessibility and storage requirements, while others faced
challenges in transporting patients to the ACSs. 153
Recommendation: Develop state models for expanding current space in medical
facilities to accommodate potential surges in patient care demand.
• Work with local partners to identify strategies and resources needed to
successfully expand existing space for patient care.
151 Cal OES. “Interim 2020 COVID-19 Pandemic (January – August) After Action/Corrective Action Report.”
December 2020.
152 Stakeholder Interview
153 Stakeholder Interview
74
COVID-19 After Action Report
Chapter 4: Medical and Health Services
• Identify best practices and develop guidance to expand space in medical
facilities. Incorporate guidance on patient intake methods, public access
requirements, and AFN accommodations.
• Work with local jurisdictions to identify all pre-determined locations and
support jurisdictions in identifying alternate locations.
• Conduct functional exercises with local jurisdictions to simulate expansion
and management of additional resources.
• Set up statewide contracts for medical and wraparound service support for
use during future disaster responses.
• Create a structured feedback mechanism to systematically collect local
jurisdiction and stakeholders' feedback on receiving and utilizing the FMS
cache.
• Conduct an assessment of “field hospitals in a box” resources used during the
pandemic. This assessment should aim to develop a comprehensive list of
necessary supplies required to support additional patients.
4.3.3 Medical Professional Shortage
Strength
Strength 4: The state increased medical personnel available to local jurisdictions and
healthcare systems.
The state expanded medical personnel by deploying
specialized teams and establishing the California
Health Corps. Deployments included California
Medical Assistance Teams (CAL-MATs), the California
National Guard, EMSA, and other medical volunteers
to assist with medical surge missions. 154 These resources,
vital from the early response stages, supported the Figure 20. California Health Corps
repatriation and transportation of cruise ship social media hiring advertisement.
passengers to the Asilomar Quarantine facility. Source: Cal OES Facebook.
A state contracted private company and CAL-MAT provided infection control training
to bolster staffing levels. They began their efforts in Tulare County and later expanded
154 Stakeholder Hotwash and Stakeholder Interview
75
COVID-19 After Action Report
Chapter 4: Medical and Health Services
statewide, with a particular focus on SNFs. 155 The California National Guard was
deployed to support medical facilities at the county level and state ACSs. EMSA
provided staffing and resource support for the administration of monoclonal antibody
sites across the state. The collaborative efforts of the California National Guard,
California Health Corps, CAL-MAT, and EMSA supported vaccination and contact
tracing operations, relieve pressure on hospitals, and enhance the quality of care in
SNFs.
The state took additional measures to increase medical provider availability. These
included expanding Paramedics' and Emergency Medical Technicians’ (EMT) scopes
of practice to work in settings such as hospitals and SNFs and allowing out-of-state
medical providers to offer their services in California. In March 2020, the state approved
approximately 81,700 out-of-state waivers, allowing medical professionals from other
states to practice within California. 156 This process temporarily waived licensing,
certification, and standard scope-of-practice requirements typically necessary for out-
of-state providers. This strategy increased the number of responders available to support
local jurisdictions.
The CDPH COVID-19 AAR and EMSA COVID-19 AAR provide additional information
regarding Medical Surge, Medical Professionals, and Volunteers. 157
Areas for Improvement and Recommendations
Area for Improvement 2: The healthcare demand swiftly depleted the pre-pandemic
workforce and volunteer capacity.
Local jurisdictions and public health systems submitted staffing requests through the
MHOAC program to address critical shortages. Then state deployed resources,
including medical registries, Disaster Healthcare Volunteers, and the Medical Reserve
Corps (MRC), to meet mutual aid requests, but the overwhelming demand quickly
depleted these staffing resources. 158
Economic and workforce factors had already constrained staffing in healthcare
facilities and SNFs before the pandemic. When COVID-19 required a sudden increase
in trained medical personnel to support the surge, the existing workforce and volunteer
155 Cal OES. “Interim 2020 COVID-19 Pandemic (January – August) After Action/Corrective Action Report.”
December 2020.
156 California Board of Registered Nursing.” Coronavirus Information Updates.” Accessed December 9, 2024.
https://www.rn.ca.gov/coronavirus.shtml.
157 CDPH. COVID-19 AAR – Medical Surge, October 2022 and EMSA. “COVID-19 AAR.”
158 Stakeholder Interview
76
COVID-19 After Action Report
Chapter 4: Medical and Health Services
capacity were insufficient to meet the demand. CDPH scaled up internal staffing to
support surge operations by contracting with multiple staffing agencies. In early spring
2020, CDPH created a deployment team to oversee and track staff deployments
statewide. 159 The state and local jurisdictions used temporary staffing agencies to fill
vacant healthcare provider positions and provide short-term medical surge staffing.
CDPH deployed over 21,000 supplemental staff across California to support facilities
during the medical surges, including the Omicron surge of winter 2021/2022. 160 During
surge periods, the state deployed 3,000 to 10,000 staff across more than 700 facilities,
clinics, and therapeutic sites from over 10 staffing agencies. 161
Recommendation: Establish partnerships with educational institutions and healthcare
organizations to create targeted and accelerated healthcare training programs.
• Recruit individuals from diverse backgrounds or career paths to transition or
upskill into healthcare roles.
• Support training initiatives in high-demand healthcare fields such as nursing.
Area for Improvement 3: Staffing contracts with inflated costs created barriers for
statewide supplemental healthcare and medical support.
While the expanded availability of contract staff reduced some pressure on medical
facilities to meet surge demands, staffing agencies capitalized on the need to fill these
positions. LTCFs and hospitals had to negotiate staffing contracts with inflated costs.
They faced a choice between closing units or paying inflated staffing agency costs,
risking significant budgetary impact. Some staffing agencies raised prices and
mandated a minimum number of staff or contracted hours, while others advertised
services they could not provide.
Initially, the state did not employ regulation or statewide contract management to
lower financial barriers for organizations that could not afford the increased costs. While
the state passed executive orders to ban overcharging for other pandemic resources,
inflated costs among staffing agencies providing medical surge support remained an
issue throughout the pandemic. Smaller and rural jurisdictions faced greater impacts
due to fewer available resources compared to larger jurisdictions.
159 CDPH. “COVID-19 AAR.” October 2022.
160 CDPH. “COVID-19 AAR.” October 2022.
161 CDPH. “COVID-19 AAR.” October 2022.
77
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Recommendation: Negotiate and regulate fair pricing for health and medical surge staff
and resources for emergencies during steady state.
• Implement a system for healthcare facilities to report cases of inflated costs or
unfair pricing practices by staffing agencies, allowing for timely intervention
and enforcement of regulations.
• Collaborate with industry stakeholders to establish fair and transparent pricing
practices for emergency staffing.
Area for Improvement 4: Contracted healthcare personnel were often undertrained and
lacked an adequate supply of personal protective equipment.
The state hired contracted healthcare personnel from third-party vendors to support
local public health efforts in testing and vaccination. Although intended to ease
operational pressures, these contractors introduced unforeseen challenges.
Contracted personnel often arrived undertrained, lacked proper fit-testing, and did not
have sufficient PPE, compromising their ability to work safely and effectively.
Burnout and concerns about virus transmission among contracted staff further
exacerbated these issues, leading to absenteeism and delays in testing and
vaccination sites. Local jurisdictions frequently stepped in to fill these gaps by providing
additional training, sourcing PPE, or, in some cases, terminating contracts. Instead of
reducing workloads, these contractors added to local responsibilities, requiring
jurisdictions to manage site logistics, address complaints, and coordinate resources. 162
Recommendation: Strengthen oversight of state-contracted healthcare personnel by
improving training programs and distribution protocols for protective equipment.
• Develop and implement a standardized, training program for state-
contracted healthcare personnel prior to deployment. Include requirements
for fit-testing and proper use of PPE to promote safe working conditions.
• Establish a certification or vetting process for staffing agencies contracted by
the state to maintain compliance with training, equipment, and quality
standards.
• Require state agencies to provide contracted personnel with adequate PPE
supplies and enforce adherence to safety protocols.
162 Stakeholder Interview
78
COVID-19 After Action Report
Chapter 4: Medical and Health Services
4.3.4 Long-term Care Surge
Strength
Strength 5: The state implemented protective measures for staff and individuals in Long-
Term Care Facilities.
In response to early 2020 outbreaks of COVID-19 in California’s SNFs and other
congregate care settings, known as the “SNF Surge,” the state strengthened infection
prevention and control practices. As infection rates increased and outbreaks grew, the
state supported these facilities in adopting preventative measures to combat COVID-
19’s spread.
On April 10, 2020, the Governor’s Office introduced comprehensive COVID-19
preventive measures to protect over 1,224 SNFs and 7,461 residential care facilities,
along with their residents and staff. These measures included limiting visitors and training
staff in infection control. The state trained and deployed 600 nurses to support
compliance with COVID-19 guidelines at these facilities. 163 State staff conducted daily
calls with nursing homes to identify needs and receive early warnings of symptomatic
patients. To manage capacity, the state decompressed facilities and established
locations specifically for COVID-19-positive patients. The Governor’s Office announced
that the USNS Mercy would take non-COVID-19 patients to decompress SNFs in the Los
Angeles area. 164
Other measures included prioritizing testing for patients discharged from hospitals to
SNFs, ensuring those who tested positive were transferred to facilities equipped to care
for them while protecting COVID-19-negative residents. 165 The state also focused on
providing PPE to facilities at higher risk of COVID-19 outbreaks.
To support medical staff, the state implemented measures to alleviate burdens on
certified nurse assistants, licensed vocational nurses, and other critical staff at SNFs.
163 Office of the Governor. “Governor Newsom Outlines Steps to Protect Residents and Employees of California
Nursing Home & Residential Care Facilities.” Apr 10, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/04/10/governor-newsom-outlines-steps-to-protect-residents-and-employees-of-
california-nursing-home-residential-care-facilities/.
164 Office of the Governor. “Governor Newsom Outlines Steps to Protect Residents and Employees of California
Nursing Home & Residential Care Facilities.” Apr 10, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/04/10/governor-newsom-outlines-steps-to-protect-residents-and-employees-of-
california-nursing-home-residential-care-facilities/.
165 Office of the Governor. “Governor Newsom Outlines Steps to Protect Residents and Employees of California
Nursing Home & Residential Care Facilities.” Apr 10, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/04/10/governor-newsom-outlines-steps-to-protect-residents-and-employees-of-
california-nursing-home-residential-care-facilities/.
79
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Facebook donated $25 million to provide $500 stipends to up to 50,000 SNF workers. 166
The state also offered free or low-cost hotel accommodations for workers exposed to
COVID-19 or testing positive but not requiring hospitalization.
4.4 Vaccinations
The state began preparing for COVID-19 vaccinations as soon as vaccines entered
development in early 2020. Preparations included monitoring vaccine progress,
reviewing federal guidance from agencies like the CDC, and developing
comprehensive distribution plans. By mid-2020, the state identified priority groups for
vaccination, such as healthcare workers and individuals at high risk of severe illness,
focusing on reaching those most vulnerable. Public awareness and education
campaigns were launched early to build confidence in the vaccines. Following the
FDA's Emergency Use Authorization and subsequent approval of COVID-19 vaccines,
the state launched its vaccination program in December 2020, prioritizing healthcare
workers and residents of LTCFs. 167 These efforts continued into 2021 and beyond,
emphasizing expanded access, increased vaccination rates, and flexible distribution
strategies to meet evolving needs.
Insufficient federal communication and fragmented distribution infrastructure created
challenges in deploying COVID-19 vaccines at the state and local levels. The state
established the Community Vaccine Advisory Committee (CVAC), a diverse panel that
guided equitable vaccine distribution and effective communication strategies. By
December 2020, local entities began administering vaccines to their communities.
Collaboration between the state, local jurisdictions, CBOs, and public-private partners
supported the vaccination of hundreds of thousands of Californians, primarily through
mass vaccination sites and drive-through facilities. As demand at mass vaccination sites
plateaued, the state and counties shifted their focus to mobile vaccination clinics,
targeting specific demographic groups to increase access and coverage.
166 Office of the Governor. “Governor Newsom Outlines Steps to Protect Residents and Employees of California
Nursing Home & Residential Care Facilities.” Apr 10, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/04/10/governor-newsom-outlines-steps-to-protect-residents-and-employees-of-
california-nursing-home-residential-care-facilities/.
167 Office of the Governor. “Governor Newsom Launches “Vaccinate all 58” Campaign based on Safety and Equity
as First Vaccines Arrive to California.” December 14, 2020. Accessed December 9, 2024
https://www.gov.ca.gov/2020/12/14/governor-newsom-launches-vaccinate-all-58-campaign-based-on-safety-
and-equity-as-first-vaccines-arrive-to-california/.
80
COVID-19 After Action Report
Chapter 4: Medical and Health Services
4.4.1 Federal Vaccine Rollout
Area for Improvement and Recommendations
Area for Improvement 1: Communication delays and breakdowns between the state
and the federal government hindered effective planning for the mass vaccination sites.
The federal government collaborated with the state to distribute vaccine doses and
establish vaccination programs. 168 However, delays and communication breakdowns
between the state and federal government disrupted logistical planning, including
vaccine distribution, availability, storage, and appointment scheduling. Uncertainties in
vaccine allocation, including defining priority groups, made it difficult to manage public
expectations and address questions about eligibility.
Inconsistent information from the federal government about the number, type, and
arrival dates of vaccine doses prevented the state and local jurisdictions from
scheduling appointments effectively. This created patient flow and staffing challenges
for vaccination programs. 169 Limited information on doses allocated to pharmacies and
health centers further complicated decisions about distributing vaccines to sites with
constrained supply.
Recommendation: Conduct regular full-scale exercises with federal and local partners
to simulate federal/state vaccine distribution and administration.
• Include objectives focused on enhancing communication and information
sharing to strengthen intergovernmental planning.
• Work with federal and local stakeholders to develop effective plans for mass
vaccination sites, including clear state guidelines.
4.4.2 State Vaccine Rollout
Strength
Strength 1: The Western States Scientific Review Workgroup addressed vaccine
hesitancy and built public confidence in COVID-19 vaccines.
The state created the COVID-19 Scientific Safety Review Workgroup to address
potential vaccine hesitancy. In May 2020, the federal government launched Operation
Warp Speed to accelerate vaccine approval and production. The FDA announced
168 GAO. “Federal and State Coordination in the COVID-19 Vaccination Response, 2021. GAO-22-104457.”
November 04, 2021.Accessed December 9, 2024. https://www.gao.gov/products/gao-22-104457.
169 Stakeholder Hotwash
81
COVID-19 After Action Report
Chapter 4: Medical and Health Services
vaccines must demonstrate at least 50% effectiveness to secure approval. Concerns
about public skepticism of accelerated vaccine development prompted the
Governor’s Office in October 2020 to convene the Workgroup, composed of
immunization and public health experts, for an additional safety review before state
authorization. 170
The Workgroup expanded to include experts from Washington, Oregon, and Nevada,
becoming the Western States Scientific Safety Review Workgroup. The group
independently evaluated the safety and efficacy of COVID-19 vaccines authorized for
emergency use by the FDA, reviewed trials and evidence, and offered
recommendations to uphold public confidence in vaccination efforts. Members
participating in FDA and CDC committees provided valuable insights into the
Workgroup. 171
The Workgroup operated on a compressed timeline, aligning its meetings with the
federal review cycle. Following FDA approval, the CDC issued guidelines, prompting the
Workgroup to convene immediately, develop recommendations, and prepare
statements for state leadership within days. Western States’ Governors issued joint
statements endorsing the vaccines, expediting public administration efforts. 172
4.4.3 MyCAvax
Strength
Strength 2: The state launched myCAvax to streamline vaccine delivery to providers.
In late 2020, the state and CDPH prepared for COVID-19 vaccine distribution by
enhancing existing systems and creating new tools for provider enrollment, vaccine
allocation, ordering, distribution, administration, and reporting. 173 The state developed
myCAvax, a statewide vaccine management application, to replace
PrepMod/COVIDReadi. This system managed provider enrollment, vaccine allocation,
order tracking, and shipment monitoring. Additionally, the state enhanced CAIR2, the
existing immunization registry, to integrate with the new system. 174
State staff and contractors collaborated to implement, train, and support myCAvax.
Teams provided updates through regular communication with providers and local
170 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
171 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
172 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
173 CDPH. “COVID-19 AAR – Vaccines.”
174 CDPH. “COVID-19 AAR – Vaccines.”
82
COVID-19 After Action Report
Chapter 4: Medical and Health Services
health jurisdictions, hosting weekly webinars and “office hours” to address system-
related questions. 175
The myCAvax team responded to the pandemic’s dynamic challenges by introducing
functionalities on an accelerated timeline. By January 2023, myCAvax supported over
9,000 providers and facilitated orders exceeding 59 million vaccine doses. 176
Area for Improvement and Recommendations
Area for Improvement 2: The state struggled to simultaneously roll out
PrepMod/COVIDReadi and rapidly develop its replacement, myCAvax.
When myCAvax was not ready in December 2020, the state temporarily used
PrepMod/COVIDReadi to bridge the gap for provider enrollment while myCAvax was
under development. 177 CDPH quickly configured and rebranded PrepMod to meet
immediate needs. Enrollment followed a tiered approach aligned with CDC guidelines,
prioritizing acute care facilities, healthcare centers, and local health jurisdictions.
However, a small CDPH team of two to three staff faced difficulties managing the time-
intensive task of verifying medical licenses, a feature PrepMod lacked. 178
Between January and February 2021, CDPH transitioned provider enrollment to
myCAvax, requiring account transfers and training for staff and providers. Early iterations
of myCAvax lacked some functionalities, necessitating ongoing enhancements. While
enrollment moved to myCAvax, vaccine ordering continued in PrepMod, creating
challenges as staff managed both systems simultaneously. 179
Recommendation: Evaluate myCAvax’s performance to prepare for future challenges
posed by pandemics and infectious disease responses.
• Conduct a thorough assessment of the existing vaccine management system
to ensure it is scalable and flexible, accommodating challenges in vaccine
supply, distribution, and administration protocols.
• Involve local health jurisdictions and other key stakeholders in the training and
implementation of the system.
• Prioritize interoperability with relevant state and federal partners and systems
such as electronic health records to streamline data sharing and reporting.
175 CDPH. “COVID-19 AAR – Vaccines.”
176 CDPH. “COVID-19 AAR – Vaccines.”
177 CDPH. “COVID-19 AAR – Vaccines.”
178 CDPH. “COVID-19 AAR – Vaccines.”
179 CDPH. “COVID-19 AAR – Vaccines.”
83
COVID-19 After Action Report
Chapter 4: Medical and Health Services
• Ensure the system can support different vaccine distribution scenarios to
prepare for future infectious disease responses.
4.4.4 My Turn
Strength
Strength 3: The state developed and implemented the My Turn Portal to manage
vaccine eligibility and appointments.
Facing unprecedented vaccine demand, the
state developed the My Turn system to manage
vaccine rollout effectively. Existing systems could
not accommodate the scale and complexity
required for efficient vaccine distribution. 180
Launched on January 25, 2021, with a $50 million
investment, My Turn provided accessible vaccine
information, enabled appointment scheduling,
Figure 21. My Turn logo and advertisement to and streamlined the upload of vaccination
sign up. Source: My Turn website. records. Providers used the platform to manage
clinics and report patient data, which simplified
vaccination administration. 181
Despite early technical challenges, My Turn centralized vaccine registration and supply
management, supporting public health outreach by sending targeted text messages
about vaccine eligibility. 182 The platform allowed self-attestation of eligibility, removing
identification or proof requirements and reducing barriers to vaccination.
As vaccine availability increased, My Turn became a critical tool for individuals to locate
nearby vaccination sites, schedule follow-up doses, and receive reminders. 183
Jurisdictions relied on the system to share vaccine administration data, manage
supplies, and reallocate doses to eligible providers. 184 To address inequities, the state
used My Turn data to implement a vaccine equity metric in March 2021. This metric,
informed by the Healthy Places Index and demographic data, directed millions of
180 CDPH. “COVID-19 AAR – Vaccines.”
181 CDPH. “COVID-19 AAR – Vaccines.”
182 Stakeholder Interview
183 Stakeholder Hotwash
184 Executive Department, State of California. “To Improve Statewide Vaccinations Governor Newsom Announces
Actions to Simplify, Standardize and Address Supply Needs.” January 25, 2021.
84
COVID-19 After Action Report
Chapter 4: Medical and Health Services
additional doses to the most affected quartiles. These efforts supported a data-driven
approach to ensuring equitable vaccine distribution and improving accessibility for
underserved communities.
Area for Improvement and Recommendations
Area for Improvement 3: The My Turn platform encountered several challenges during
its initial rollout.
Initially, My Turn faced user challenges such as incomplete vaccine records and
individuals arriving at incorrect locations or times for appointments. The platform lacked
functionality to modify existing records, requiring administrators to create new ones,
which slowed vaccine tracking. Users also encountered language barriers, website
malfunctions, and periodic downtime caused by high user volume. 185 Providers could
not directly create clinics in the system and instead relied on CDPH contractors to
manage clinics using Excel spreadsheets.
My Turn’s rapid rollout struggled to keep pace with changing vaccine eligibility criteria.
Frequent updates to eligibility required significant programming adjustments, causing
glitches and delays in reflecting current guidelines. 186 Technical issues also resulted in
incomplete dose logging, with the platform capturing only 27% of daily vaccinations,
falling short of the state’s 24-hour reporting requirement. 187,188
The public interface further limited functionality, restricting appointments to mass
vaccination sites and certain county health departments, while excluding retail
pharmacies and grocery stores receiving federal vaccine allocations. Limited system
capacity for high-demand sites created a perceived shortage of appointments,
leading to frustration during peak vaccination periods. 189 Although later system updates
improved My Turn’s functionality, stakeholders described the updates as insufficient and
delayed. By the time improvements were fully implemented, most large-scale vaccine
clinics had already concluded operations. 190
185 Stakeholder Interview
186 Stakeholder Interview
187 Stakeholder Interview
188 CDPH. “COVID-19 Vaccination Plan.” October 16, 2020. Accessed December 9, 2024
https://www.cdph.ca.gov/programs/cid/dcdc/cdph%20document%20library/covid-19/covid-19-vaccination-plan-
california-interim-draft_v1.0.pdf.
189 Stakeholder Interview
190 Stakeholder Interview
85
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Though the state implemented system updates and improved accessibility to address
reported issues with My Turn over time, several stakeholders noted the implementation
as “too little, too late.” 191 They pointed out that by the time these enhancements were
fully implemented, most of the larger vaccine clinics were concluding their
operations. 192
Recommendation: Enhance the functionality and accessibility of the My Turn Platform.
• Revamp the My Turn interface to facilitate smoother navigation and user-
friendly scheduling of vaccine appointments. Ensure the platform's
compatibility with multiple devices, languages, and accessibility features to
cater to diverse user needs.
• Implement system upgrades to ensure accurate and real-time logging of all
administered vaccine doses. Address glitches that cause underreporting of
vaccination data by enhancing the system's capacity to capture and record
all vaccination activities.
• Develop a flexible system to swiftly adapt to changing eligibility criteria.
• Expand My Turn to include a wider range of vaccination sites and increase slot
availability.
• Create training on the use of My Turn and conduct this training with state, local,
and private response partners regularly.
• Exercise the use of My Turn with state, local, and private response partners
regularly to identify and mitigate technical and human error issues impacting
system access and function.
4.4.5 Third Party Administrator
Strength
Strength 4: Blue Shield of California simplified and standardized the vaccination process,
focusing on equity as the third-party administrator.
On January 27, 2021, the state selected Blue Shield of California to oversee its COVID-
19 vaccination network as the third-party administrator (TPA). Blue Shield managed the
vaccine provider network under state public health guidance, streamlining vaccine
distribution by enrolling providers, allocating doses, tracking data, and standardizing
processes. 193 The centralized approach required third-party vaccine vendors to operate
191 Stakeholder Interview
192 Stakeholder Interview
193Blue Shield of California. “Q&A: Blue Shield of California as the State of California's third-party administrator.”
March 19, 2021. Accessed December 9, 2024. https://news.blueshieldca.com/2021/03/19/q-a-blue-shield-of-
california-as-the-state-of-californias-third-party-administrator
86
COVID-19 After Action Report
Chapter 4: Medical and Health Services
through a state-managed system rather than local agreements. 194 This network
incorporated healthcare entities such as public health systems, pharmacies, hospitals,
community health centers, and mobile sites, prioritizing high-volume providers to
maximize efficiency and equity in vaccine distribution. 195
Area for Improvement and Recommendations
Area for Improvement 4: The state announced the third-party administrator after many
local entities had already developed vaccine provider management plans.
When the state announced Blue Shield as the TPA, many local entities were already
implementing vaccine distribution plans and had identified eligible providers through
existing agreements. The sudden shift introduced challenges for local jurisdictions that
had spent months coordinating agreements with healthcare partners and organizing
distribution events. 196 The state’s policy restricted the use of these established
agreements, leaving local jurisdictions with less time to adjust to the new requirements.
This proved especially difficult in areas where few state-approved TPA providers had the
capacity to support localized vaccination outreach.
Recommendation: Update the statewide mass vaccine distribution plan that
incorporates lessons learned from the pandemic and addresses local needs.
• Collaborate with local response partners to identify best practices and lessons
learned from the COVID-19 vaccination campaign. Use this input to update a
statewide distribution plan that addresses vaccine storage, transportation,
resource needs, Point of Dispensing (POD) site mobilization, and public
communication strategies.
• Establish a working group to refine the plan, outline an implementation
strategy, and conduct regular exercises to test its effectiveness.
• Collaborate with trusted local partners who bring community-specific
knowledge and existing relationships from the COVID-19 vaccination effort to
improve outreach and distribution.
194 CalHHS. “Newsom Administration Supplements Vaccine Delivery System; Announces Creation of Statewide
Vaccine Delivery Network to Simplify and Standardize Vaccination Process with Equity as a Core Focus.” January
26, 2021. Accessed December 9, 2024. https://www.chhs.ca.gov/blog/2021/01/26/newsom-administration-
supplements-vaccine-delivery-system-announces-creation-of-statewide-vaccine-delivery-network-to-simplify-and-
standardize-vaccination-process-with-equity-as-a-core-focus/.
195 CalHHS. “Newsom Administration Supplements Vaccine Delivery System; Announces Creation of Statewide
Vaccine Delivery Network to Simplify and Standardize Vaccination Process with Equity as a Core Focus.” January
26, 2021. Accessed December 9, 2024. https://www.chhs.ca.gov/blog/2021/01/26/newsom-administration-
supplements-vaccine-delivery-system-announces-creation-of-statewide-vaccine-delivery-network-to-simplify-and-
standardize-vaccination-process-with-equity-as-a-core-focus/.
196 Stakeholder Interview
87
COVID-19 After Action Report
Chapter 4: Medical and Health Services
4.4.6 State Vaccination Sites
Strengths
Strength 5: Mass vaccination sites were strategically located to enhance accessibility
and efficiency in vaccine distribution.
In February 2021, the state launched its first mass vaccination sites in Oakland and Los
Angeles, sponsored by Federal Emergency Management Agency (FEMA) in partnership
with Cal OES and CDPH. 197 Federal and local partners collaborated with the state to
identify site locations based on population diversity and vulnerability. These sites aimed
to improve vaccine access for individuals at greater risk from the pandemic. During the
first week of operations, 2,000-3,000 doses were administered daily, increasing to 8,000-
9,000 doses per day by the second week. 198 Both sites operated under FEMA and Cal
OES and concluded operations in mid-April
2021. 199
Cal OES Fire and Rescue led incident command for
both sites as they became operational for vaccine
distribution. The Los Angeles site relied on a trained
army unit that established infrastructure, including
backup generators for proper vaccine storage,
while Department of Defense medical personnel
administered vaccines. 200 The Oakland site Figure 22. National Guard member
involved collaboration among multiple managing traffic at Oakland COVID-19
stakeholders, with the California National Guard vaccination site. Source: Cal OES.
managing traffic and other federal and state agencies, such as Cal OES Fire and
Rescue, CAL FIRE and Caltrans, providing additional support. 201
Strength 6: Mobile and home-based vaccination clinics expanded access and equity
by adapting to vaccination trends through a statewide initiative.
The state transitioned from mass vaccination sites to targeted mobile and home-based
clinics, tailoring services to specific demographic needs. 202 Mobile vaccination clinics
provided flexible options, while home-based programs deployed medical personnel to
197 CDPH. “COVID-19 AAR – Vaccines.”
198 CDPH. “COVID-19 AAR – Vaccines.”
199 CDPH. “COVID-19 AAR – Vaccines.”
200 CDPH. “COVID-19 AAR – Vaccines.”
201 CDPH. “COVID-19 AAR – Vaccines.”
202 Stakeholder Interview
88
COVID-19 After Action Report
Chapter 4: Medical and Health Services
residential facilities and homes. 203 These initiatives supported individuals with AFN,
expanding equitable vaccine access.
The equity-focused mobile vaccination strategy included pop-up clinics at accessible
sites such as schools, churches, malls, and grocery stores. These events minimized
barriers by offering language support, flexible hours, transportation, and walk-in services.
The state partnered with community leaders, deployed medical strike teams, and
prioritized underserved areas, including neighborhoods, food banks, and senior
centers. 204 For example, some counties collaborated with local farms to vaccinate
agricultural workers when they became eligible. 205
4.4.7 Equitable Vaccine Administration
Strength
Strength 7: The Community Vaccine Advisory Committee guided equitable vaccine
distribution and communication efforts.
The state established the CVAC, a group of 77 organizations representing tribal nations,
labor unions, faith-based groups, and senior advocates, among others. The CVAC
reflected California’s diverse population and advised the Vaccine Task Force on
equitable vaccine distribution and communication strategies. Members also strategized
ways to share vaccine-related information, such as availability, safety, and
effectiveness, with their communities.
Between late 2020 and mid-2021, CVAC held 15 meetings, producing extensive input
and written recommendations for the Vaccine Task Force. The CVAC model highlighted
how diverse community engagement could guide equitable public health responses
during a crisis.
4.5 Mass Fatality Management
The pandemic’s surge in fatalities overwhelmed the death care industry, even as
California maintained one of the nation’s lowest death rates. COVID-19 stretched the
state’s capacity for mass fatality management, revealing gaps in planning for large-
203 Stakeholder Interview
204 CDPH. “COVID-19 AAR – Vaccines.”
205 Stakeholder Interview
89
COVID-19 After Action Report
Chapter 4: Medical and Health Services
scale incidents. 206 Cal OES implemented the State of California Coroners’ Mutual Aid
Plan and coordinated efforts to supply critical equipment to counties. However,
resource shortages and limited pre-planning for a global pandemic constrained
counties' ability to manage the overwhelming loss of life effectively.
4.5.1 Mass Fatality Planning
Strength
Strength 1: Cal OES Law Enforcement Branch utilized the California Mass Fatality
Management Guide to support the overwhelming loss of life during the pandemic.
The rising number of fatalities strained healthcare and funeral operations, exceeding
the ability of coroners and medical examiners to hold bodies until burial services could
be arranged. Cal OES Law Enforcement Branch addressed these challenges by
applying the California Mass Fatality Management Guide, an annex to the State of
California Coroners’ Mutual Aid Plan. The guide offered a framework for an organized
state response, providing guidance on handling mortality rates, maintaining respectful
and timely decedent care, and minimizing disruptions to healthcare facilities. 207
Area for Improvement and Recommendations
Area for Improvement 1: Fatality management planning lacked sufficient provisions to
address infectious diseases and other incidents with statewide impacts.
Challenges during the COVID-19 response highlight the need for a more comprehensive
plan to address incidents in times where traditional mutual aid is unavailable. While Cal
OES did rely on the framework laid out in the California Mass Fatality Management
Guide, stakeholders determined that the guide contained a vast amount of reference
material that was not useful in a widespread pandemic-level operation where resources
were scarce. 208
206 Office of the Governor. “Governor Newsom Marks End of California’s COVID-19 State of Emergency.” February
28, 2023. Accessed December 9, 2024. https://www.gov.ca.gov/2023/02/28/governor-newsom-marks-end-of-
californias-covid-19-state-of-emergency/
207 Cal OES. “Plans in Place to Assist Counties Statewide with Rising Number of COVID-19 Decedents (UPDATED).”
January 11, 2021. Accessed December 9, 2024. https://news.caloes.ca.gov/plans-in-place-to-assist-counties-
statewide-with-rising-number-of-covid-19-decedents-updated/.
208 Stakeholder Interview
90
COVID-19 After Action Report
Chapter 4: Medical and Health Services
Recommendation: Update, expand, train, and exercise the California Coroners’ Mutual
Aid Plan and its supplement, the California Mass Fatality Management Guide.
• Include a pandemic-specific fatality management section tailored for
infectious disease outbreaks.
• Meet with response partners at the local and state level to discuss best
practices and lessons learned from fatality management during the COVID-19
response.
• Engage stakeholders from various sectors to provide input and COVID-19
related insights during the plan development.
• Exercise the plan with jurisdictions to include agencies that would respond to
a local, regional, and statewide fatality management incident.
4.5.2 Mass Fatality Resources
Strength
Strength 2: Cal OES coordinated the distribution of refrigerated trailers to support mass
fatality management efforts across the state.
County officials, overwhelmed by the surge in fatalities, turned to Cal OES for
refrigerated trailers to support mass fatality management efforts. Cal OES Law
Enforcement Branch organized weekly regional conference calls with Area Coroner
Coordinators to oversee the allocation of trailers and other resources, such as PPE and
body bags, across the state. By January 11, 2021, Cal OES distributed 98 refrigerated
trailers to counties. To improve functionality, Cal OES outfitted non-morgue trailers with
shelving, doubling their capacity. Additionally, Cal OES leased 20 trailers to serve as
temporary morgues in Imperial, Sonoma, San Bernardino, Riverside, Monterey, and Los
Angeles Counties. 209
Los Angeles County experienced the largest surge in fatalities, with over 11,000 COVID-
19-related deaths, comprising 40% of the state’s total as of January 15, 2021. 210 Cal OES
collaborated with the county to establish a temporary morgue adjacent to the Los
Angeles County Coroner’s facility. Together, they deployed five 53-ft. trailers and
additional ground refrigerated storage containers to address the county’s needs.
209 Cal OES. “Plans in Place to Assist Counties Statewide with Rising Number of COVID-19 Decedents (UPDATED).”
January 11, 2021. Accessed December 9, 2024. https://news.caloes.ca.gov/plans-in-place-to-assist-counties-
statewide-with-rising-number-of-covid-19-decedents-updated/.
210 Cal OES. “Plans in Place to Assist Counties Statewide with Rising Number of COVID-19 Decedents (UPDATED).”
January 11, 2021. Accessed December 9, 2024. https://news.caloes.ca.gov/plans-in-place-to-assist-counties-
statewide-with-rising-number-of-covid-19-decedents-updated/.
91
COVID-19 After Action Report
Chapter 5: Logistics
CHAPTER 5: LOGISTICS
CHAPTER INTRODUCTION
The state’s response to COVID-19 became one of its
“These actions marshal
largest logistical operations in history. It met
the generosity and unprecedented demands for PPE, specialized medical
innovative spirit of supplies, and vaccine distribution, reaching tens of millions
Californians to help us of Californians. Coordination across sectors connected
achieve two essential communities with critical resources while prioritizing
goals: getting more equitable access. The state’s strong contract execution
lifesaving supplies into our and procurement systems supported not only California
health care system and but extended aid to other states and nations.
increasing our testing
capacity.” State leaders adapted regulations and procurement
- Governor Newsom processes to meet the scale and speed required for this
April 4, 2020
emergency. Executive orders, policies, and streamlined
guidance expedited resource mobilization for state and
local partners. DGS issued procurement guidelines that safeguarded against
exploitative practices, such as price gouging, while ensuring efficient supply delivery.
The private sector played a key role in the response.
On April 4, 2020, the Governor’s Office launched the
COVID-19 supplies website, operational within 24 days
of WHO’s pandemic declaration. 211 This platform
enabled businesses, organizations, and individuals to
donate, sell, or manufacture essential medical supplies
like N95 respirators and ventilators. 212 Innovative
approaches, such as the California Manufacturers and
Technology Association’s Safely Making California Figure 23. Governor Newsom announces
the launch of COVID-19 supplies website
Marketplace, created a uniform framework for vetted on April 4, 2020. Source: Office of the
businesses to sell PPE. Additionally, the state engaged Governor
unconventional partners, including alcoholic beverage manufacturers, to produce
211 Cucinotta D, Vanelli M. “WHO Declares COVID-19 a Pandemic. Acta Biomed.” March 2020 19;91(1):157-160. doi:
10.23750/abm.v91i1.9397.
212 Cucinotta D, Vanelli M. “WHO Declares COVID-19 a Pandemic. Acta Biomed.” March 2020 19;91(1):157-160. doi:
10.23750/abm.v91i1.9397.
92
COVID-19 After Action Report
Chapter 5: Logistics
hand sanitizer. 213 These collaborations streamlined resource availability and provided
critical lessons about working with private partners during emergencies.
To manage the scale of operations, the state overhauled its logistics systems. In March
2020, the Logistics and Commodity Movement Task Force was established to distribute
resources statewide. The state also partnered with Salesforce to implement a digital
Customer Relationship Management platform, modernizing resource request
management. This system facilitated coordination among agencies and local partners,
contributing to an efficient logistical response. The state’s innovations in logistics provide
valuable lessons for future disaster preparedness.
State Logistics Priorities
Supply Chain Management
• Procured and distributed PPE and essential supplies to support response
operations, such as healthcare facilities, educational institutions, and CBOs.
• Maintained a consistent supply of medical equipment and pharmaceuticals.
• Adapted inventory reporting methods to enhance resource tracking and
coordination.
• Monitored and addressed disruptions in the supply chain.
• Coordinated with federal agencies to secure additional resources and
support.
• Replenished strategic stockpiles for critical supplies and maintained seven
warehouses for receiving, distributing, and storing supplies.
Testing Distribution
• Mobilized and demobilized testing sites.
• Coordinated the distribution of test kits.
Medical Material Management
• Deployed Battelle Mask Decontamination Systems to expand the PPE supply,
support mission continuity, and aid healthcare systems.
• Mobilized and demobilized FMS and ACSs throughout the state.
Vaccine Distribution
• Developed a comprehensive vaccination distribution plan.
• Distributed vaccines to healthcare providers, LTCFs, and the public.
• Implemented a tracking system to monitor vaccine administration.
Recovery and Resilience
• Assessed the impact on logistics and healthcare infrastructure.
• Coordinated efforts to establish a new statewide multi-agency inventory
system and standardized inventory reporting procedures.
213 Stakeholder Interview
93
COVID-19 After Action Report
Chapter 5: Logistics
FINDINGS
This chapter explores the emergency response logistics functions, including resource
procurement and management. It discusses acquiring resources from government and
private sectors, using emergency contracts and Salesforce for efficient allocation. It also
addresses warehouse and donation management and resource-sharing among
agencies for effective coordination.
5.1 Resource Procurement
Medical supplies were scarce during the early stages of the pandemic. The state
prioritized closing the gap between supply and demand. Federal resources from the
SNS proved inadequate, with some supplies arriving expired or damaged. A shortage
of ventilators made it challenging for healthcare facilities to treat COVID-19 cases. EMSA
led efforts to procure and distribute ventilators, ultimately acquiring enough to support
healthcare providers statewide.
The state collaborated with private sector partners to bridge supply gaps by working
with vetted vendors and manufacturers through initiatives like the Safely Making
California Marketplace, which facilitated the distribution of PPE across various sectors.
Task forces also supported non-PPE industry companies in producing and donating
essential goods like hand sanitizer and masks, increasing the availability of critical
resources.
DGS managed contracts to secure supplies and distribute them to essential workers and
medical facilities. The state implemented Salesforce to streamline resource
management, transforming the resource request process into an automated, customer-
centric system. This new system enhanced the efficiency of tracking and fulfilling
resource requests, providing real-time metrics for informed decision-making. Despite
initial challenges and confusion over ordering procedures, the Salesforce system
improved resource allocation and reduced duplication of efforts, ultimately facilitating
a more efficient response.
94
COVID-19 After Action Report
Chapter 5: Logistics
5.1.1 Government Resources
Strength
Strength 1: The Logistics and Commodity Movement Task Force facilitated and
maintained the supply chain by acquiring critical resources for the state.
The task force coordinated the acquisition of critical supplies such as masks, hand
sanitizer, and gloves for response partners. Working with the Army Corps of Engineers,
the task force oversaw contracts to expand hospital capacity and capabilities. This
collaboration, in partnership with EMSA, served as a testament to their comprehensive
approach to managing the state’s healthcare infrastructure. 214 The collaboration
highlighted the task force’s ability to coordinate a diverse range of resources, support
various partner response efforts, and contribute to the expansion of medical facilities
and public health capabilities.
As public health guidance on supplies and equipment evolved, the Logistics and
Commodity Movement Task Force adapted its strategies to meet the demands of a
dynamic response. For example, in April 2020, the FDA introduced a method to
decontaminate N95 respirators using vaporized hydrogen peroxide gas plasma
sterilization. 215 The task force worked with hospitals to implement this process, aligning
efforts with the specific needs of healthcare organizations. The California National
Guard significantly bolstered these operations by providing specialized expertise,
logistical capabilities, and critical resources such as transportation and warehousing.
Their involvement strengthened the task force’s ability to scale operations, address
supply chain challenges, and execute rapid deployments to meet the evolving needs
of the response. 216
Collaborating with CDE, the task force provided masks and hand sanitizer to
educational partners. Distribution was based on the number of faculty and students to
ensure equitable distribution of supplies. For more information on the items provided to
the educational institutions, refer to Chapter 8: Education.
214 Stakeholder Interview
215 U.S. Food and Drug Administration. “Coronavirus (COVID-19) Update: FDA Issues Emergency Use Authorization to
Decontaminate Millions of N95 Respirators.” April 12, 2020. Accessed December 9, 2024. https://www.fda.gov/news-
events/press-announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-
decontaminate-millions-
n95#:~:text=The%20U.S.%20Food%20and%20Drug,care%20workers%20in%20hospital%20settings.
216 Stakeholder Interview
95
COVID-19 After Action Report
Chapter 5: Logistics
Area for Improvement and Recommendations
Area for Improvement 1: The lack of critical resources hampered the effectiveness of
the state's response during the initial pandemic phase.
At the pandemic's onset, the state struggled to secure
critical resources such as PPE from the SNS, which
impacted its ability to respond effectively. In March
2020, the state requested resource support from
USDHHS, including PPE and ventilators, to protect
healthcare and frontline workers. However, the SNS
allocation fell short, with only 75% of the requested
supplies delivered, including expired and unusable N95
Figure 24. Governor Newsom, Mayor
respirators. 217 The absence of functional ventilators Liccardo, and Bloom Energy CEO KR
further strained the response, leaving counties like Los Sridhar visit the ventilator refurbishing site
Angeles dependent on refurbished ventilators, which in Sunnyvale. Source: Cal OES.
delayed deployment during critical surges. 218
DGS procured 1,000 ventilators to address critical shortages, with EMSA supporting the
effort through its procurement contracts. 219 These efforts, combined with additional
contracts, enabled the state to acquire 15,602 ventilators by June 2022. The state’s
proactive measures mitigated resource gaps, ensuring healthcare providers could
respond more effectively to the pandemic. 220 For more details on EMSA’s efforts, refer to
the EMSA COVID-19 AAR.
Recommendation: Maintain a state-level strategic stockpile and conduct routine
assessments to identify gaps in critical supplies or scarce resources.
• Partner with vendors to secure essential supplies during shortages, ensuring
compliance with procurement regulations.
• Conduct routine quality control checks to verify that supplies meet
deployment standards.
217 Cal OES. “Interim 2020 COVID-19 Pandemic (January – August) After Action/Corrective Action Report.”
December 2020.
218 Cal OES. “Interim 2020 COVID-19 Pandemic (January – August) After Action/Corrective Action Report.”
December 2020.
219 Stakeholder Hotwash
220 CalHHS and Cal OES. “COVID-19 Situation Report, Report No. 494.” June 29, 2022.
96
COVID-19 After Action Report
Chapter 5: Logistics
5.1.2 Private Sector Resources
Strengths
Strength 2: Private sector partners supported logistics operations by developing and
distributing essential public health resources and supplies throughout the response.
The scarcity of PPE and other medical resources
presented challenges for the state. The state
collaborated with private sector partners to address
critical supply shortages and meet immediate
requirements for essential resources. 221 As a result,
companies in the region tackled the need and
manufactured essential goods such as hand sanitizer
and masks, often employing creative and innovative
Figure 25. Screenshot of "Safely Making
California” video, featuring a worker methods to meet the critical demand. For example,
crafting non-medical grade masks. ABC authorized alcoholic beverage manufacturers to
Source: Safely Making California website. repurpose their equipment to produce hand
sanitizer. 222 In addition, the state partnered with California’s Manufacturing and
Technology Association to launch the Safely Making California Marketplace, which
enabled the vetting of private businesses to sell PPE to all sectors using a uniform
procurement framework. 223 This effort bridged supply gaps and improved PPE
accessibility across California during the early pandemic response.
Additional PPE procured via contracts with third-party vendors benefited the state in
numerous ways. It reduced COVID-19 transmission and alleviated strain on healthcare
systems and workers. It permitted businesses to operate safely, allowed the flow of
goods and services in communities to resume, and protected essential workers. It also
facilitated the safe reopening of schools, faith-based organizations, and other
important community institutions.
221 Cal OES. “Interim 2020 COVID-19 Pandemic (January – August) After Action/Corrective Action Report.”
December 2020.
222 ABC. “Second Notice of Regulatory Relief.” April 1, 2020. Accessed December 9, 2024.
https://www.abc.ca.gov/abc-announces-that-bars-wineries-breweries-and-distilleries-will-be-able-to-sell-drinks-to-
go/.
223 Stakeholder Interview
97
COVID-19 After Action Report
Chapter 5: Logistics
Strength 3: The state collaborated with BYD North America to address scarce resource
production and distribution across the state.
On June 8, 2020, the Governor’s Office announced a
partnership with BYD North America to procure large
quantities of surgical and N95 masks. This partnership
aimed at equipping frontline workers and responders
with the necessary PPE for their response efforts. 224 The
contract supported the state’s broader effort to
acquire and distribute critical PPE and emergency Figure 26. Nevada County PPE distribution.
resources for public health and safety workers. Source: Cal OES.
By June 8, 2020, the state’s contract with BYD yielded more than 110 million masks, which
were distributed to the following sectors in the chart below: 225
Construction and Hotels and Lodging,
Trade, 232,000 402,000
Public Works and
Utilities, 228,000
Education,
2,578,000
Non-emergency Public Health
Medical, (Local
Construction and Government),
3,516,000
Trade, 232,000 8,696,000
Transportation
(Transit, Ports), Retail,
514,000 3,238,000 Communications
Infrastructure,
Agriculture, 6,000
6,168,000
Business/Office
Social Services, Workspaces,
74,000 320,000
224 Office of the Governor. “Governor Newsom Announces Federal Health and Safety Certification of Life-Saving
N95 Maks.” June 8, 2020. Accessed December 9, 2024. https://www.gov.ca.gov/2020/06/08/governor-newsom-
announces-federal-health-and-safety-certification-of-life-saving-n95-masks/.
225 Office of the Governor. “Governor Newsom Announces Federal Health and Safety Certification of Life-Saving
N95 Maks.” June 8, 2020. Accessed December 9, 2024. https://www.gov.ca.gov/2020/06/08/governor-newsom-
announces-federal-health-and-safety-certification-of-life-saving-n95-masks/.
98
COVID-19 After Action Report
Chapter 5: Logistics
The state distributed these masks to chambers of commerce statewide, nonprofit
organizations, trade associations, faith-based groups, schools, counties, medical
facilities, tribal nations, and 59 consulate general offices throughout the state. The state
launched a PPE distribution program to coordinate large-scale delivery to essential
workers statewide. 226
5.1.3 Emergency Contracts
Strength
Strength 4: Emergency authority expedited the manufacturing and procurement of
critical supplies.
The Governor's Office leveraged emergency authority under the ESA to expedite the
procurement of critical supplies. Executive Order N-46-20 suspended specific revenue
and taxation codes, along with provisions in the California Code of Regulations, to
simplify contracting and purchasing processes for essential goods. 227 These measures
encouraged private companies to collaborate with the state on vital public health
initiatives. The state also expanded sole-source contracting, allowing faster acquisition
of supplies during a time when traditional procurement methods proved insufficient.
To prevent exploitative practices, Executive Order N-
44-20 addressed price gouging. Signed on April 4,
2020, the order prohibited businesses from increasing
prices on critical goods by more than 50% above their
pre-pandemic cost of production. This protection
extended to food, consumer goods, medical supplies,
and other resources designated by the U.S. Secretary
of Health and Human Services as scarce or
Figure 27. Consumer warning for
Executive Order prohibiting critical threatened, pursuant to section 102 of the Defense
supplies price gouging. Production Act, Title 50 U.S.C. § 4512, and waived time
Source: California Department of Justice limitations under California Penal Code §396. 228 Initially
website. set to expire in September 2020, the state extended
the order multiple times to maintain market stability
and protect Californians throughout the response.
226 Stakeholder Interview
227 Executive Department, State of California. “Executive Order N-46-20.” April 7, 2020. https://www.gov.ca.gov/wp-
content/uploads/2020/04/4.7.20-EO-N-46-20.pdf.
228 Executive Department, State of California. “Executive Oder N-44-20.” April 3, 2020. https://www.gov.ca.gov/wp-
content/uploads/2020/04/4.3.20-EO-N-44-20.pdf.
99
COVID-19 After Action Report
Chapter 5: Logistics
5.1.4 Resource Management System
Strength
Strength 5: The resource management system streamlined coordination efforts, resulting
in the delivery of over 1.8 billion items statewide.
The state adopted a resource management system, Salesforce, to overcome
challenges in processing and fulfilling resource requests during the pandemic. This
system replaced the outdated medical and health resource request process, which
had relied on paper and email, by integrating it with the state’s electronic emergency
management platform. 229 This transition consolidated workflows, reduced
redundancies, and enhanced supply tracking.
The resource management system processed over 40,000 resource requests and
facilitated the distribution of more than 1.8 billion items, including PPE and healthcare
supplies, to stakeholders statewide. State personnel used real-time dashboards to
monitor inventory levels, funding allocations, and order statuses. These tools supported
strategic purchasing decisions, anticipated resource gaps, and improved coordination
throughout the response. 230
The system linked resource requests to shipping vendors, streamlining fulfillment, and
minimizing delays. By integrating the medical and health resource process with the
emergency management platform, the state reduced duplicate requests and
enhanced supply distribution efficiency to local and regional partners. This
modernization addressed critical gaps in resource management, strengthening
statewide coordination and response capabilities during the large-scale emergency.
Area for Improvement and Recommendations
Area for Improvement 2: Local agencies faced challenges navigating the state’s
multiple resource request procedures.
Local agencies struggled with submitting and processing resource requests due to the
state’s various systems and procedures. Under SEMS, resource requests followed distinct
pathways: medical and health requests moved through MHOACs and RDMHC/S to the
state level, while non-medical resources, such as law enforcement and fire services,
were routed through local EOCs to regional centers and then to the SOC.
229 Cal OES. “Interim 2020 COVID-19 Pandemic (January – August) After Action/Corrective Action Report.”
December 2020.
230 Stakeholder Interview
100
COVID-19 After Action Report
Chapter 5: Logistics
To address these inefficiencies, the state implemented a centralized resource
management platform, integrating medical and non-medical resource requests while
maintaining proper adjudication for medical needs. This platform reduced request
duplication and improved the tracking and processing of resource needs.
Despite these advancements, local agencies often found the updated processes
confusing. Some agencies submitted duplicate requests through multiple pathways,
complicating resource allocation. 231 While the centralized system mitigated many
operational challenges, the complexity of transitioning to the new procedures remained
a significant barrier during the response.
Recommendation: Continue to develop and unify the framework across the separate
ordering systems for Emergency Management, Medical and Health, Schools, Fire, and
Law.
• Develop and distribute standardized guidelines offering clear, actionable
steps for all stakeholders.
• Provide ongoing training for local agencies to effectively use the centralized
system.
• Implement features such as automated detection of duplicate requests to
streamline processes and minimize delays.
5.2 Resource and Donations Management
The state created a donation management system to coordinate contributions from
foreign governments, private vendors, non-profits, and the public. This system provided
donors with a centralized contact point and tracked all donations through the state’s
inventory system. Starting with a 10,000-square-foot warehouse, the state expanded its
capacity to address increased demand for resources. The state’s COVID-19 stockpile
supported other states and extended international aid, including oxygen supplies to
India and PPE to South Asian nations.
231 Stakeholder Hotwash
101
COVID-19 After Action Report
Chapter 5: Logistics
5.2.1 Warehouse Management
Area for Improvement and Recommendations
Area for Improvement 1: Resource inventory management and distribution efforts
revealed a need for acquiring a larger warehouse facility.
As the pandemic began, Cal OES relied on a single 10,000-square-foot warehouse and
federal SNS resources to meet demand for essential PPE and supplies. 232 This reliance
underscored the critical need for enhanced state-level resource management and
larger dedicated stockpiles.
To address these challenges, the state partnered with
UPS to manage seven strategically located
warehouses, which became central hubs for resource
storage and distribution. A tracking system provided
by FedEx streamlined supply management and
expedited order processing. The state rapidly
expanded its response infrastructure to 2.5 million
square feet, enabling effective distribution of critical Figure 28. Warehouse featuring COVID-19
resources statewide. PPE donations. Source: Cal OES.
As demand for supplies stabilized during the recovery phase, the state reduced its
operational footprint to 586,000 square feet, reflecting a dynamic response to shifting
needs. 233 The expanded warehouse capacity supported the state’s pandemic response
and enabled aid to out-of-state partners and foreign nations. However, as operations
normalized, the state reverted to its initial capacity, relinquishing the robust infrastructure
developed during the response phase.
Recommendation: Establish and maintain dedicated, scalable warehouse operations
facilities to address resource management challenges.
• Invest in scalable, dedicated warehouse facilities strategically located across
the state, supported by regular space utilization assessments.
• Establish agreements with state agencies to share warehouse space, enabling
cost-sharing and resource optimization.
• Formalize MOU/MOAs with logistics providers like UPS and FedEx to maintain
surge capacity during emergencies.
232 Stakeholder Hotwash
233 Stakeholder Interview
102
COVID-19 After Action Report
Chapter 5: Logistics
• Conduct regular assessments and exercises to refine warehouse operations
and ensure readiness for future emergencies.
5.2.2 Donations Management
Strength
Strength 1: The donations management system provided a single contact point to
coordinate contributions.
The Logistics and Commodity Movement Task Force established a centralized donations
management system at the state level, departing from the traditional local-level
approach. This system coordinated contributions across California’s 58 counties,
allowing businesses and organizations to communicate directly with a single point of
contact. Given the pandemic’s statewide impact, this centralized approach enhanced
efficiency and provided continuity for both donors and recipients. 234
The Office of Private Sector and NGO Coordination led this effort through the Logistics
and Commodity Movement Task Force and Contributions Workgroup. 235 The system
tracked all donations in the state’s inventory system and distributed supplies to local
stakeholders based on documented needs and requests. By utilizing Salesforce for
donation management, the state consolidated donation records, provided clear
visibility into inventory levels, and generated real-time data for state dashboards. This
functionality allowed state personnel to effectively allocate PPE and other critical
supplies to meet stakeholder demands.
Donors included foreign governments, private
vendors, non-profits, and the public, contributing
critical items such as KN-90 and KN-95 masks, surgical
masks, face shields, and hand sanitizer. While
procurement met the majority of the state’s needs,
donations bolstered readiness and supported rapid
response efforts.
Figure 29. Forklift operator in the state
warehouse. Source: Cal OES.
234 Stakeholder Interview
235 The Office of Private Sector / NGO Coordination.” COVID-19 After-Action Report Questionnaire.” 2020.
103
COVID-19 After Action Report
Chapter 5: Logistics
5.2.3 Resource Sharing
Strength
Strength 2: The COVID-19 supply stockpile supported numerous out-of-state partners,
including six other nations.
By June 2020, the state maintained a robust inventory of critical resources, enabling swift
responses to internal surges while extending support to external partners. Cal OES
collaborated with FEMA through the Emergency Management Assistance Compact to
fulfill requests for life-saving equipment from other states. 236 This partnership facilitated
the distribution of 17 million surgical masks and additional supplies to western states,
strengthening regional efforts against COVID-19. 237
In April 2021, California became the first U.S. state to provide aid to India during its severe
COVID-19 outbreak. The state shipped 275 oxygen concentrators, 440 oxygen cylinders,
240 oxygen regulators, 210 pulse oximeters, and one deployable oxygen concentrator
system. Coordinated through the U.S. Agency for International Development, these
supplies targeted healthcare providers and frontline workers in high-need areas. 238
In June 2021, Cal OES extended assistance to South
Asia amid another surge in COVID-19 cases, providing
249,600 Rapid Diagnostic Tests, 96,000 goggles, and
450,000 isolation gowns. 239 While extending aid, the
state maintained a strategic resource reserve to
address potential new outbreaks domestically,
demonstrating a balanced approach to resource
management.
Figure 30. Warehouse staging COVID-19
PPE donations. Source: Cal OES.
236 Stakeholder Interview
237 Cal OES. “California Distributes Millions of Additional PPE to Out-of-State Partners.” June 29, 2020. Accessed
December 9, 2024. https://news.caloes.ca.gov/california-distributes-millions-of-additional-ppe-to-out-of-state-
partners/
238 Office of the Governor. “California Sends India COVID-19 Supplies to Combat Outbreak.” April 26, 2021.
Accessed December 9, 2024. https://www.gov.ca.gov/2021/04/26/california-sends-india-covid-19-supplies-to-
combat-outbreak/
239 Cal OES. “California to Send Additional COVID-19 Supplies to South Asian Countries.” June 2021.Accessed
December 9, 2024. https://news.caloes.ca.gov/california-to-send-additional-covid-19-supplies-to-south-asian-
countries/
104
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
CHAPTER 6: SOCIAL SERVICES AND
ECONOMIC RELIEF
CHAPTER INTRODUCTION
The COVID-19 pandemic abruptly disrupted daily life worldwide and created substantial
socio-economic challenges, particularly for those facing heightened risks of infection
and economic hardship. California experienced some of the earliest impacts in the
United States, prompting the rapid implementation of innovative solutions to address
the needs of its diverse population and economy. The state responded with
extraordinary legislative measures, launching economic assistance programs for
individuals who lost jobs, faced housing instability, or struggled to pay utility bills, as well
as for small businesses critical to the state’s economy. These legislative actions provided
critical financial support and legal protections, mitigating the pandemic’s impacts on
lives and livelihoods.
The state coordinated its social services response to support extended operations and
reduce community hardships. CDSS, leading the effort in collaboration with CDPH,
delivered timely and equitable access to essential resources for those most affected by
economic challenges. These joint efforts enabled the rapid mobilization of programs
offering food assistance, housing services, and healthcare resources to those in need.
The state introduced innovative relief initiatives such as Project Roomkey, Project
Homekey, and Housing for the Harvest, which became some of the most impactful
programs in its history.
Although relief programs aimed to assist all Californians and reduce hardship,
implementation proved complicated. The desire to expedite aid occasionally caused
confusion or unforeseen hurdles among those responsible for executing and managing
these programs. California, like the rest of the nation, grappled with the widespread
issue of fraudulent unemployment claims. Despite these challenges, the relief programs
offered crucial and lifesaving assistance to many across the state.
State Social Services and Economic Relief Priorities
Financial Assistance
• Provided written guidance, technical assistance, and funding coordination to
counties to support individuals experiencing homelessness.
105
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
• Facilitated access to the CA COVID19 Rent Relief program, covering unpaid
rent or utilities for eligible renters and landlords affected by COVID-19-related
financial hardships.
• Implemented the Supplemental Paid Sick Leave, allowing workers to take paid
leave for COVID-19-related illness or caregiving responsibilities.
• Distributed Golden State Stimulus Checks to provide direct financial relief to
low-income Californians.
• Offered Pandemic Unemployment Assistance (PUA) to provide financial
assistance during pandemic.
Housing and Shelter Support
• Assisted counties in securing, equipping, and staffing properties, including
hotels, motels, and trailers, through Project Roomkey and Housing for the
Harvest.
• Provided clear communication about housing rights and resources to
Californians, property owners, and local jurisdictions.
• Supported efforts to rehouse individuals previously sheltered in Project
Roomkey facilities or other COVID-19-related interim housing.
Feeding Operations
• Supported food banks and local food systems in addressing food insecurity.
• Allocated funding and resources to support food banks, ensuring access to
food for individuals facing supply shortages.
Case Management
• Provided technical assistance to social workers and case managers, ensuring
the health and safety of Californians and clients.
• Addressed reports of abuse and neglect through protective services, including
case management, supportive services, and care.
Public Health and Safety Monitoring
• Monitored service programs aligned with public health guidance to support
local agencies in addressing resource gaps.
106
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
FINDINGS
This section offers an overview of the state's efforts to support economic relief and social
services. It covers the state’s economic relief initiatives, feeding operations, and non-
congregate sheltering efforts.
6.1 Economic Relief
Lockdowns and social distancing measures severely disrupted sectors such as travel,
hospitality, retail, and entertainment, causing widespread job losses, surging
unemployment rates, and financial strain on small businesses. In response, the state
launched legislative actions and relief initiatives, including the Golden State Stimulus,
Earned Income Tax Credit, and Small Business COVID-19 Relief Grant Program. These
programs provided direct financial assistance or tax credits without requiring
applications, easing financial burdens and promoting stability for individuals and
businesses. Initiatives like the PUA program injected substantial financial support into the
economy, countering job losses and sustaining consumer spending power amid
unprecedented unemployment rates.
6.1.1 Relief Programs
Strength
Strength 1: The state implemented a series of legislative actions and relief programs to
promote economic stability.
The state acknowledged that layoffs, missed work, and lost income would leave many
Californians unable to cover essential household expenses. On April 2, 2020, the
governor signed Executive Order N-28-29, preventing water service shutoffs for
consumers unable to pay due to pandemic-related financial hardship. 240 On August 31,
2020, legislation AB 3088 extended protections for tenants facing eviction and property
owners at risk of foreclosure due to COVID-19’s economic impacts. These measures
applied to tenants who declared their inability to pay rent in full or in part because of
the pandemic. 241
240 Office of the Governor. “Governor Newsom Issues Executive Order Protecting Homes, Small Businesses from
Water Shutoffs.” April 2, 2020. Accessed December 9, 2024. https://www.gov.ca.gov/2020/04/02/governor-newsom-
issues-executive-order-protecting-homes-small-businesses-from-water-shutoffs/.
241 Office of the Governor. “Governor Newsom Signs Statewide COVID-19 Tenant and Landlord Protection
Legislation.” August 31, 2020. Accessed December 9, 2024. https://www.gov.ca.gov/2020/08/31/governor-newsom-
signs-statewide-covid-19-tenant-and-landlord-protection-legislation/.
107
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
“People are trying to On January 29, 2021, the governor enacted the COVID-19
find jobs and make ends Tenant Relief Act (SB 92), extending eviction protections for
meet and one of the struggling renters. 242 Recognizing the impact on landlords,
greatest needs is to the state enacted AB 832 on June 28, 2021, which provided
extend the evictions financial assistance to landlords to cover unpaid rent while
moratorium—which continuing protections for tenants. 243
includes maximizing the
federal funds available In February 2021, the state introduced a comprehensive
to help the most tenants package to address economic hardships faced by
and landlords possible— individuals, families, and businesses. Programs such as the
so that they can count Golden State Stimulus, Earned Income Tax Credit, Small
on a roof over their Business COVID-19 Relief Grant Program, and College
heads while their Affordability were instrumental in providing financial relief
finances rebound.” and fostering economic stability.
- Senate President Pro
Tempore Toni G. Atkins These efforts supported households across California,
on June 25, 2021 promoting equity and economic stability for those most in
need.
Table 2: State Relief Programs and Purpose
Program Purpose/Activities
Golden State Stimulus The Golden State Stimulus provided stimulus payments to
families and individuals who filed 2020 tax returns. The
program supported those facing financial hardships during
the pandemic, including low and middle-income
Californians. The state provided two different stimulus
payments, and individuals could qualify for one or both,
depending on their income level. 244
Earned Income Tax The California Earned Income Tax Credit provided a
Credit refundable cash-back benefit to low- and moderate-
income Californians. When combined with the federal
Earned Income Tax Credit and the Young Child Tax Credit,
this program delivered significant financial support, offering
242 BCSH. “COVID-19 Tenant Relief Act.” https://www.bcsh.ca.gov/covidrelief /.
243 BCSH. “Landlords – Protection Information.” Accessed December 9, 2024.
https://housing.ca.gov/landlord/protection_guidelines.html#:~:text=Many%20landlords%20have%20also%20felt,AB%
20832%2C%20provides%20some%20relief.
244 California Franchise Tax Board. “Golden State Stimulus.” Accessed December 9, 2024.
https://www.ftb.ca.gov/about-ftb/newsroom/golden-state-stimulus/index.html.
108
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
hundreds to thousands of dollars to families and individuals
who filed their 2020 taxes. 245
Small Business COVID- The Small Business COVID-19 Relief Grant Program offered
19 Relief Grant Program grants from $5,000 to $25,000 to eligible small businesses and
nonprofits impacted by COVID-19 and the related health
and safety restrictions. 246
College Affordability The governor signed legislation to enhance college
affordability and expand access to higher education during
the COVID-19 pandemic. These bills aimed to boost transfer
rates for underserved students, improve access to financial
aid, and increase affordable housing options to address the
student housing crisis. The legislation also established a
budget prioritizing affordability, accessible institutions, high-
quality programs, equitable outcomes, and streamlined
degree pathways. 247
6.1.2 Individual Relief
Strength
Strength 2: Pandemic Unemployment Assistance delivered financial support to workers
during their period of greatest economic hardship.
As the pandemic began, millions of people across the state faced job losses and
financial instability. 248 On March 27, 2020, only eight days after the state’s stay at home
orders took effect, legislators signed the PUA program into law under the federal
Coronavirus Aid, Relief, and Economic Security (CARES) Act. The California Employment
Development Department (EDD) administered PUA, which provided up to 86 weeks of
benefits from February 2, 2020, to September 4, 2021, expanding eligibility to self-
employed individuals, freelancers, and gig workers who traditionally did not qualify for
unemployment benefits.
245 California Department of Community Services and Development. “California Earned Income Tax Credit.”
Accessed December 9, 2024. https://www.csd.ca.gov/Pages/CalEITC.aspx.
246 California Grants Portal. “California Small Business COVID-19 Relief Grant Program.” May 26, 2023. Accessed
December 9, 2024. https://www.grants.ca.gov/grants/california-small-business-covid-19-relief-grant-program/.
247 Office of the Governor. “Governor Newsom Signs College Affordability and Accessibility Legislation, Highlights
$47.1 Billion Higher Education Package.” October 06, 202. Accessed December 9, 2024.
https://www.gov.ca.gov/2021/10/06/governor-newsom-signs-college-affordability-and-accessibility-legislation-
highlights-47-1-billion-higher-education-package/.
248 EDD. “Pandemic Unemployment Assistance.” Accessed July 2023.
https://edd.ca.gov/en/about_edd/coronavirus-2019/pandemic-unemployment-assistance.
109
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
By July 2020, PUA had paid out approximately $37.5 billion, reflecting its substantial
impact. Recipients received an additional $600 per week on top of their standard
benefits until the end of July 2020. 249 The program alleviated financial strain for millions
of workers and contributed to economic stability by maintaining consumer spending
power during a period of unprecedented job losses, with unemployment peaking at
16.4% in May 2020. 250
Area for Improvement and Recommendations
Area for Improvement 1: The Pandemic Unemployment Assistance program
encountered $20 billion in fraudulent activities.
The state rapidly implemented the PUA program to provide financial assistance to
workers impacted by the pandemic. In its rush to deliver these benefits, the program
bypassed traditional protective measures and checks, making it a target for extensive
fraudulent activities. 251 A lack of protective measures, combined with the existence of
a thriving underground market for stolen personal information, facilitated fraudulent
claims on a massive scale. Since 2020, EDD has recouped approximately $6 billion and
made numerous arrests and convictions. 252
Recommendation: Implement fraud detection and prevention measures during the
application stage to mitigate risks in future programs.
• Integrate advanced fraud detection systems by employing real-time identity
verification technologies and behavioral analytics to identify and flag
suspicious activity during the application process.
• Collaborate with cybersecurity specialists, fraud detection experts, and law
enforcement agencies to design robust fraud prevention frameworks.
• Conduct systematic auditing schedules to monitor program integrity, assess
vulnerabilities, and respond to emerging threats.
• Develop educational campaigns to raise public awareness about fraud risks,
prevention measures, and reporting mechanisms.
249 Cal OES News. “Unemployment benefits to pandemic-impacted workers reach $63.9 billing.” Augus 13, 2020.
Accessed December 9, 2024. https://news.caloes.ca.gov/unemployment-benefits-to-pandemic-impacted-workers-
reach-63-9-billion/.
250 California Department of Finance. “California Budget Summary 2021-22.” Accessed December 9, 2024.
https://ebudget.ca.gov/2021-22/pdf/BudgetSummary/EconomicOutlook.pdf.
251 LAO. “Assessing Proposals to Address Unemployment Insurance Fraud.” February 15, 2022. Accessed December
9, 2024. https://lao.ca.gov/Publications/Report/4542.
252 EDD. “The EDD’s Response to Fraud.” Accessed December 9, 2024. https://edd.ca.gov/en/about_edd/fraud-
response/.
110
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
6.1.3 Business Relief
Area for Improvement and Recommendations
Area for Improvement 2: Statewide closures, compounded by financial disparities,
disproportionately impacted small businesses and perpetuated their challenges.
State closure orders, designed to protect public
health and mitigate long-term economic damage,
had a disproportionate impact on smaller
businesses. Many small enterprises struggled to
access aid due to complex application processes or
stringent eligibility requirements, which excluded
them from critical assistance. 253 Businesses owned by
individuals from historically underserved and
disadvantaged communities faced additional Figure 31. Social media post on July 13,
barriers in securing capital, despite representing 99.8 2020, calling for the immediate closure of
percent of the state’s enterprises and supporting business indoor operations.
nearly half of all jobs in California. 254 Without vital Source: California Governor Facebook.
financial support, many of these businesses
experienced significant revenue losses, leading to permanent closures.
Small businesses lacked the financial reserves and technological infrastructure of larger
corporations, hindering their ability to adapt to pandemic-related restrictions. While
larger companies leveraged their resources to invest in online sales platforms, remote
work technologies, and safety measures, smaller businesses faced overwhelming
obstacles. 255 Family-owned restaurants, for example, often lacked the means to
develop online ordering systems or implement social distancing protocols, resulting in
closures or severely reduced operations. Similarly, small retail stores without e-commerce
capabilities struggled to survive prolonged closures, in stark contrast to larger retailers
who quickly shifted to online sales and curbside pickup models.
253 California State Assembly, Joint Committee on Economic Development and Emerging Technologies. "JEDE
Briefing Report: COVID-19 and Small Business." February 23, 2021. Accessed January 4, 2024.
https://ajed.assembly.ca.gov/sites/ajed.assembly.ca.gov/files/5FINAL%20-
%20Feb%2023%20JEDE%20Briefing%20Report-COVID-19%20and%20Small%20Business.pdf.
254 California Department of Finance. "State Fiscal Recovery Fund: California's Recovery Plan." July 29, 2022.
Accessed January 4, 2024. https://dof.ca.gov/wp-content/uploads/sites/352/budget/covid-19/state-fiscal-
recovery-fund/2022-Recovery-Plan-FINAL-2022-07-29.pdf.
255 Stakeholder Interviews
111
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
Recommendation: Strengthen support for small businesses by creating contingency
plans for closures and targeted financial relief programs.
• Create tailored financial assistance programs specifically designed for small
businesses most affected by statewide closures, with streamlined application
processes to improve accessibility.
• Establish technical support resources or online platforms to provide technical
assistance and guidance to businesses during closures.
• Introduce tax incentives or relief programs to help small businesses invest in
technology upgrades, safety measures, and online infrastructure.
• Create accessible training and education programs, including workshops, to
equip business owners with tools and strategies to adapt during emergencies.
6.2 Non-Congregate Sheltering Operations
Implementing non-congregate sheltering operations provided a critical solution for
individuals needing safe isolation but lacking adequate housing options. The state
recognized unique challenges faced by agricultural workers who played an essential
role in maintaining the food supply chain. As community transmission increased, many
farmworkers and food processing employees struggled to isolate due to crowded or
communal living conditions. To address this issue, the state, in collaboration with local
and regional partners, launched the Housing for the Harvest program, offering essential
isolation and quarantine facilities for farmworkers. This program safeguarded their health
and safety while supporting vital agricultural operations.
Similarly, Project Roomkey utilized federal funds and local collaborations to secure
temporary housing for those experiencing homelessness. By offering hotel and motel
rooms, the program provided a safe environment for isolation, contributing to public
health safety and easing the transition to more permanent living situations. Despite its
successes, Project Roomkey encountered financial challenges, prompting calls for
sustainable planning to address future non-congregate sheltering needs.
Project Homekey, introduced in July 2020, built on these efforts by focusing on acquiring
and converting properties to provide long-term housing solutions for individuals
experiencing homelessness or housing instability. The program represented the state’s
commitment to addressing the intertwined issues of public health and housing insecurity,
demonstrating a forward-thinking approach to emergency management and social
services.
112
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
6.2.1 Housing for the Harvest Program
Strength
Strength 1: The Housing for the Harvest program provided non-congregate housing to
farmworkers who tested positive for COVID-19.
Agricultural and food processing employees ensured food supply continuity throughout
the pandemic. However, increasing community transmission left many of these essential
workers unable to isolate effectively due to shared or densely populated housing
arrangements, which heightened the risk of virus spread.
The state collaborated with local governments and
community partners to establish the Housing for the
Harvest program, providing temporary, non-
congregate sheltering options for farmworkers
exposed to or testing positive for COVID-19. The
program offered hotel rooms in participating
counties and coordinated services such as meals
and wellness checks. 256 Initial efforts focused on
Figure 32. Housing for the Harvest post on regions with significant agricultural workforces,
November 9, 2020. including the Central Valley, Central Coast, and
Source: CDPH Facebook. Imperial County, and expanded as additional
counties opted into the program. This initiative
enabled farmworkers to isolate safely, protecting public health while maintaining
essential agricultural operations.
6.2.2 Project Roomkey
Strength
Strength 2: Project Roomkey provided safe and isolated temporary housing to those
experiencing homelessness.
Project Roomkey, leveraging FEMA funding and state-local partnerships, secured
approximately 15,000 hotel and motel rooms to provide safe isolation spaces for
individuals experiencing homelessness. 257 This effort reduced virus transmission and
256 California Department of Food and Agriculture. “Housing for the Harvest – Program Overview Document.”
Accessed July 2023. https://files.covid19.ca.gov/pdf/Housing_for_the_Harvest-Program_Overview.pdf.
257 Cal OES. “Project Roomkey: Impact to Date and Looking Ahead.” August 3, 2021. Accessed December 3, 2024.
https://news.caloes.ca.gov/project-roomkey-impact-to-date-and-looking-ahead/.
113
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
alleviated pressure on healthcare systems. Participants gained
Project Roomkey
access to critical services, including mental and physical provided safe
healthcare, which supported their transition to more stable shelter to more
housing.
than 22,300
Californians
Project Roomkey supported non-congregate sheltering and
experiencing
provided safe accommodations for displaced individuals,
homelessness.
reducing reliance on congregate shelters that could exacerbate
disease spread. Overall, Project Roomkey offered shelter to more
than 22,300 Californians, including 6,600 individuals in Los Angeles County. 258
Area for Improvement and Recommendations
Area for Improvement 1: Some local governments faced challenges securing
accommodations to support Project Roomkey.
Some counties encountered difficulties leasing hotel
rooms for non-congregate sheltering. Initially, some
hotel operators withdrew from agreements upon
learning the rooms would house individuals
experiencing homelessness rather than medical
professionals or first responders. As travel resumed and
cases declined, several hotels prioritized regular
operations, forcing counties to relocate current
Figure 33. Project Roomkey logo.
Source: Cal OES News website.
occupants and reevaluate their long-term sheltering
strategies.
Project Roomkey’s operational costs significantly exceeded those of traditional
congregate shelters, posing sustainability challenges for counties, particularly after
federal CARES Act funding expired. 259
Recommendation: Develop a plan to update Project Roomkey by integrating lessons
learned.
• Assess homelessness at the county level to determine jurisdiction-specific
needs and tailor resource allocation accordingly.
258 Cal OES News. “Governor Newsom Announces Emergency Allocation of $62 Million to Local Governments to
Protect People Living in Project Roomkey Hotels.” November 16, 2020. Accessed December 3, 2024,
https://news.caloes.ca.gov/governor-newsom-announces-emergency-allocation-of-62-million-to-local-
governments-to-protect-people-living-in-project-roomkey-hotels/.
259 Alameda County Office of Homeless Care and Coordination. “Evaluating Project Roomkey in Alameda
County.” May 2021. Accessed December 9, 2024. https://homelessness.acgov.org/homelessness-
assets/img/reports/Final%20PRK%20Report.pdf.
114
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
• Gather feedback from local agencies and stakeholders to understand their
experiences with Project Roomkey.
• Establish clear contractual agreements with hotel operators, addressing
liability and insurance concerns to streamline future partnerships
• Monitor and evaluate the program's effectiveness, focusing on serving
populations disproportionately affected by homelessness and identifying at-
risk individuals.
• Partner with private and public entities to create additional funding streams
and resources, ensuring the program’s long-term viability.
6.2.3 Project Homekey
Strength
Strength 3: The Homekey initiative served as a strategic resource in addressing
homelessness.
In July 2020, the state launched Project Homekey to tackle homelessness by converting
underutilized properties into affordable housing. The program allocated $800 million to
enable local public agencies to purchase and repurpose properties, such as hotels and
motels, into permanent housing units for individuals experiencing or at risk of
homelessness. 260, 261 Within six months, cities and counties acquired 94 properties,
creating 6,000 new housing units and significantly increasing the state's affordable
housing inventory. 262
Encouraged by its initial success, the state expanded Project Homekey in July 2021. The
governor signed legislation providing an additional $2.75 billion to the program as part
260 California Department of Housing and Community Development. “Notice of Funding Availability: Homekey
Program.” July 16, 2020. Accessed December 9, 2024. https://www.hcd.ca.gov/grants-funding/active-
funding/homekey/docs/2020_hcd_homekey-nofa_07-15-2020.pdf.
261 Tener Center for Affordable Housing and Community Development, University of California, Berkeley.
“California’s Homekey Program: Unlocking Housing Opportunities for People Experiencing Homelessness.” March
2022. Accessed December 9, 2024. https://ternercenter.berkeley.edu/wp-content/uploads/2022/03/Homekey-
Lessons-Learned-Final-March-2022.pdf.
262 Office of the Governor. “Governor Newsom Signs Historic Housing and Homelessness Funding Package as Part of
$100 Billion California Comeback Plan.” July 19, 2021. Accessed December 9, 2024.
https://www.gov.ca.gov/2021/07/19/governor-newsom-signs-historic-housing-and-homelessness-funding-package-
as-part-of-100-billion-california-comeback-plan/#:~:text=Plan%20%7C%20California%20Governor-
,Governor%20Newsom%20Signs%20Historic%20Housing%20and%20Homelessness%20Funding%20Package%20as,%24
100%20Billion%20California%20Comeback%20Plan&text=Package%20includes%20%245.8%20billion%20to,with%20se
vere%20mental%20health%20challenges.
115
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
of the broader $100 billion California Comeback Plan. 263 This included $10.3 billion for
affordable housing and $12 billion over two years for homelessness initiatives, aiming to
help tens of thousands transition off the streets while holding local governments
accountable for their progress. 264
Project Homekey required public entities to act as primary applicants. This approach
encouraged partnerships with a diverse range of organizations, including nonprofits and
community groups not traditionally involved in housing development. By broadening
participation, the program enhanced its impact and reach, contributing to a
comprehensive approach to homelessness and housing insecurity. 265
6.3 Feeding Operations
As part of Operation Feed California, California Volunteers (Cal Volunteers)
collaborated with state agencies to bolster food bank capacity, utilizing California
National Guard resources and personnel to meet the increased demand for food
banks. Operation Feed California launched a collaboration among state agencies,
nonprofits, and individuals, creating a statewide volunteer network to support food
banks. The state sought partnerships with the private sector in its Great Plates Delivered
program, the first of its kind in the nation.
263 Office of the Governor. “Governor Newsom Signs Historic Housing and Homelessness Funding Package as Part of
$100 Billion California Comeback Plan.” July 19, 2021. Accessed December 9, 2024.
https://www.gov.ca.gov/2021/07/19/governor-newsom-signs-historic-housing-and-homelessness-funding-package-
as-part-of-100-billion-california-comeback-plan/#:~:text=Plan%20%7C%20California%20Governor-
,Governor%20Newsom%20Signs%20Historic%20Housing%20and%20Homelessness%20Funding%20Package%20as,%24
100%20Billion%20California%20Comeback%20Plan&text=Package%20includes%20%245.8%20billion%20to,with%20se
vere%20mental%20health%20challenges.
264 Office of the Governor. “Governor Newsom Signs Historic Housing and Homelessness Funding Package as Part of
$100 Billion California Comeback Plan.” July 19, 2021. Accessed December 9, 2024.
https://www.gov.ca.gov/2021/07/19/governor-newsom-signs-historic-housing-and-homelessness-funding-package-
as-part-of-100-billion-california-comeback-plan/#:~:text=Plan%20%7C%20California%20Governor-
,Governor%20Newsom%20Signs%20Historic%20Housing%20and%20Homelessness%20Funding%20Package%20as,%24
100%20Billion%20California%20Comeback%20Plan&text=Package%20includes%20%245.8%20billion%20to,with%20se
vere%20mental%20health%20challenges.
265 Tener Center for Affordable Housing and Community Development, University of California, Berkeley. “Homekey:
Lessons Learned." March 2022. https://ternercenter.berkeley.edu/wp-content/uploads/2022/03/Homekey-Lessons-
Learned-Final-March-2022.pdf.
116
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
6.3.1 Great Plates Delivered
Strength
Strength 1: Great Plates Delivered provided over 37 million meals to seniors and other
high-risk adults who opted into the program.
The pandemic posed significant challenges for seniors
and high-risk adults attempting to adhere to stay at
home orders while accessing basic needs like
nutritious meals. At the same time, public health
restrictions impacted the restaurant and hospitality
industries, causing economic downturns and job
losses.
Figure 34. Great Plates Delivered
On April 24, 2020, the Governor’s Office announced infographic. Source: Great Plates
the initiation of the Great Plates Delivered program. Delivered X (formerly Twitter).
The program had two primary goals: (1) Delivering
three nutritious meals a day to seniors and adults at high-risk from COVID-19 and (2)
Providing essential economic stimulus to local businesses struggling to stay afloat during
the pandemic.
The program partnered local governments with food and restaurant sectors to deliver
meals to those in need. Restaurants temporarily closed due to COVID-19 were engaged
to prepare and distribute meals, ensuring nutritional needs were met while limiting
exposure risks for vulnerable populations.
Great Plates Delivered prioritized equity by supporting minority-owned businesses, with
nearly 60% of participating food providers identifying as minority-owned. 266 This
approach reflected the diversity of the communities served while fostering economic
opportunities for underrepresented groups.
At its peak, the program operated through ten Area Agencies on Aging, 19 counties,
and 21 cities statewide. Over 800 local food businesses participated, sustaining more
than 9,500 jobs. Ultimately, Great Plates Delivered supported over 55,000 older adults
and delivered more than 37 million meals, demonstrating its effectiveness in addressing
food insecurity and supporting local economies. 267
266 Stakeholder Interview
267 Cal OES News. "A Comprehensive Look: Landmark COVID-19 Relief Program Great Plates Delivered Wraps Up
Operations." July 2, 2021. Accessed December 9, 2024. https://news.caloes.ca.gov/a-comprehensive-look-
landmark-covid-19-relief-program-great-plates-delivered-wraps-up-operations/.
117
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
Area for Improvement and Recommendations
Area for Improvement 1: The Great Plates Delivered program was announced before its
mission or objectives were communicated to the counties.
The Great Plates Delivered program, despite its successes,
“The Great Plates
Delivered program’s had limited engagement with local stakeholders during the
success is an example planning phase. 268 The state prioritized a rapid launch to
of what’s possible address urgent needs, but local jurisdictions were unprepared
when federal, state, when the Governor’s Office announced the program.
and local leaders set Without prior communication or implementation guidance,
aside politics and local authorities and community partners scrambled to
come together to understand the program’s details and processes.
protect our
communities from the Shortly after the announcement, local call centers were
threat of COVID-19,” overwhelmed with inquiries from residents seeking services
-Governor Newsom
and vendors looking to participate. Unprepared for this surge
and lacking critical information about the program, call
centers struggled to respond effectively. This strain delayed the program's benefits,
creating additional challenges for those in need.
Additionally, only 40 local governments participated in the program. While some
jurisdictions had the financial capacity to implement the program, others lacked the
resources to cover upfront costs. 269 Smaller and less economically advantaged
communities were particularly impacted. Uncertainty around potential reimbursement
further deterred participation, despite state guidance released on May 4, 2020,
clarifying FEMA’s reimbursement for Great Plates Delivered. 270
Recommendation: Provide implementation guidance and supporting documentation,
including reimbursement information, to local governments prior to the public
announcement of a program.
• Coordinate a conference call with Operational Areas to discuss upcoming
programs, policies, and initiatives, including reimbursement procedures.
• Provide a document addressing frequently asked questions to help jurisdictions
communicate effectively with their communities.
268 Stakeholder Interviews and Stakeholder Hotwashes
269 Stakeholder Interviews
270 Cal OES. “California Department of Aging, and CalHHS. Great Plates Delivered Program Guidance." California
Governor’s Office of Emergency Services.” Accessed January 3, 2023.https://www.caloes.ca.gov/wp-
content/uploads/Recovery/Documents/037-great-plates-delivered-program-guidance-AS-OF-05042020.pdf.
118
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
6.3.2 California Volunteers
Strength
Strength 2: California Volunteers supported volunteer management for food banks and
food supply chains.
The pandemic’s economic impacts, including job
losses and income reductions, significantly increased
food insecurity statewide. Food banks faced demand
up to six times higher than normal while simultaneously
experiencing a decline in their volunteer workforce.
Many regular volunteers were older adults or
individuals at higher risk of COVID-19 who could no
longer safely participate. This reduction in personnel
Figure 35. December 25, 2020, post
strained food banks as they worked to sort, pack, and highlighting Operation Feed California’s
distribute food to meet surging needs. 271 efforts to provide 306 million meals to
families affected by the pandemic.
Source: Operation Feed California
In April 2020, the Governor’s Office launched
Facebook.
Operation Feed California, a statewide initiative to
support food banks and combat food insecurity. This collaborative effort between state
agencies, nonprofits, and individuals mobilized a volunteer network to sustain food bank
operations and ensure Californians had access to meals. 272
Cal Volunteers partnered with Cal OES and the California National Guard to provide
critical support. The California National Guard was deployed to 36 food bank sites in 26
counties, assisting with distribution and delivery. 273 Nearly 800 state agency
representatives and nonprofit partners, including the California Conservation Corps,
Civil Air Patrol California Wing, AmeriCorps VISTA, American Red Cross, and Team
Rubicon, joined these efforts. Operation Feed California became a model for activating
271 California Volunteers. “Operation Feed California.” Accessed December 9, 2024.
https://www.californiavolunteers.ca.gov/wp-content/uploads/sites/116/2021/03/Operation-Feed-California-Fact-
Sheet-1.pdf.
272 California Volunteers. “Operation Feed California.” Accessed December 9, 2024.
https://www.californiavolunteers.ca.gov/wp-content/uploads/sites/116/2021/03/Operation-Feed-California-Fact-
Sheet-1.pdf.
273 California Volunteers.” California volunteers deploys AmeriCorps VISTA members to support long-term sustainable
food bank strategy.” September 2, 2020. Accessed December 9, 2024.
https://www.californiavolunteers.ca.gov/california-volunteers-deploys-americorps-vista-members-to-support-long-
term-sustainable-food-bank-
strategy/#:~:text=%E2%80%9CAt%20the%20start%20of%20the,Chief%20Service%20Officer%20Josh%20Fryday.
119
COVID-19 After Action Report
Chapter 6: Social Services and Economic Relief
and coordinating volunteers during emergencies, ensuring food banks could meet
unprecedented demand. 274
274 California Volunteers. “California volunteers deploys AmeriCorps VISTA members to support long-term sustainable
food bank strategy.” September 2, 2020. Accessed December 9, 2024.
https://www.californiavolunteers.ca.gov/california-volunteers-deploys-americorps-vista-members-to-support-long-
term-sustainable-food-bank-
strategy/#:~:text=%E2%80%9CAt%20the%20start%20of%20the,Chief%20Service%20Officer%20Josh%20Fryday.
120
COVID-19 After Action Report
Chapter 7: Correctional Facilities
CHAPTER 7: CORRECTIONAL
FACILITIES
CHAPTER INTRODUCTION
Correctional facilities presented a unique set of obstacles to the state’s response given
the communal setting and political concerns. The rapid spread of COVID-19 early in
prisons heightened emphasis on infection prevention and control. Outbreaks required
swift and coordinated action, driving closer collaboration with state agencies, including
the CDCR and California Correctional Health Care Services (CCHCS).
Acknowledging the risks of shared living conditions, the
state took measures to reduce facility populations,
conduct testing, provide PPE, and facilitate
vaccination campaigns. These actions aimed to
protect correctional facility staff and inmates and to
prevent outbreaks from spreading into surrounding
communities.
The state issued several executive orders and policies Figure 41. Correctional facility staff
affecting correctional facilities. Executive Order N-36- member wearing PPE. Source: CDCR
website.
20 directed the CDCR Secretary to temporarily
suspend inmate and juvenile intakes or transfers to state facilities. CDCR and CCHCS
implemented a range of protocols to maintain safety, including restrictions on visitation,
mandatory testing, PPE distribution, and the establishment of quarantine and isolation
protocols to manage outbreaks.
State Correctional Facilities Priorities
Inmate Health and Safety
• Reduced COVID-19 exposures in correctional facilities through preventive
measures.
• Implemented isolation and quarantine for confirmed cases and close
contacts.
• Maintained coordinated, accurate communication between CDCR program
areas and stakeholders.
121
COVID-19 After Action Report
Chapter 7: Correctional Facilities
Testing and Contact Tracing
• Mandated testing for inmates, staff, and visitors.
• Implemented a tracking system to monitor testing and contact tracing.
• Collaborated with local officials to conduct contact tracing for confirmed
cases within prisons and upon inmate release.
Resource Supplies
• Procured and distributed PPE to support response operations.
Expanding Capacity
• Increased inmate releases to decompress the prison population and maximize
space for physical distancing, and isolation/quarantine efforts.
Vaccination Distribution
• Developed a comprehensive vaccination distribution plan.
• Administered vaccines equitably as they became available.
• Implemented a tracking system to monitor vaccine administration.
FINDINGS
This chapter highlights the state's response efforts in correctional facilities, focusing on
coordination, safety measures, and inmate release initiatives. The Correctional Facilities
Coordination section examines strategies to organize and manage responses in
correctional settings. The Safety Measures subsection reviews actions taken to protect
inmates, staff, and visitors. Lastly, the Inmate Release section explores the state's
approaches to release inmates safely and responsibly during the pandemic.
7.1 Coordination
The state coordinated extensive efforts within the corrections system to protect the
health and safety of inmates and staff during the COVID-19 response. These actions
included activating the DOC through CDCR to establish a unified and organized
response framework. CDCR facilitated daily conference calls among correctional
facilities, state authorities, and local agencies, enabling efficient resource allocation
and communication.
In March 2020, CDCR took early infection control measures by suspending out-of-state
parole and inmate transfers to California for 30 days and reducing inmate transfers
122
COVID-19 After Action Report
Chapter 7: Correctional Facilities
overall to minimize exposure risks. 275 A critical component of the state’s coordination
was the establishment of a Corrections Task Force, which addressed challenges and
managed outbreaks in correctional facilities. The state’s response to an outbreak at San
Quentin highlighted the task force's support for the San Quentin DOC and its Incident
Management Team (IMT). This was reinforced by Executive Order N-36-20, which
directed specific measures to prevent the spread of COVID-19 in CDCR facilities.
CDCR implemented a range of measures, including comprehensive education on
COVID-19 prevention for staff, inmates, and visitors. Staff entering facilities underwent
symptom screenings, while cleaning and sanitation efforts were intensified.
7.1.1 Department Operations Center
Strength
Strength 1: California Department of Corrections and Rehabilitation’s Department
Operations Center streamlined decision-making and coordination to mitigate
outbreaks in correctional facilities.
The DOC served as a central location for leadership and experts to monitor situations,
prepare for events, and make timely decisions. Its primary objectives included reducing
virus transmission in correctional facilities, maintaining operational continuity, and
acquiring necessary PPE.
The DOC facilitated regular communication with correctional facilities, local public
health agencies, and CDPH through daily conference calls. These calls provided a
platform to share critical information, address resource gaps, and establish priorities. This
collaboration guided the development of CDCR’s guidance on visiting regulations,
testing protocols, and the use of facial coverings for staff and inmates.
7.1.2 Inmate Transfers
Area for Improvement and Recommendations
Area for Improvement 1: Insufficient inmate transfer protocols and poor infection control
measures contributed to significant outbreaks among staff and inmates.
Inmate transfers between facilities accelerated the spread of COVID-19 due to
insufficient health and safety protocols. The June 2020 outbreak at San Quentin
275 Office of the Governor. "Executive Order N-36-20." State of California” March 24, 2020. Accessed December 9,
2024. https://www.gov.ca.gov/wp-content/uploads/2020/03/3.24.20-EO-N-36-20.pdf.
123
COVID-19 After Action Report
Chapter 7: Correctional Facilities
exemplifies these failures. During this transfer, 122 inmates were moved from the
California Institution for Men in Chino, which was already experiencing a severe
outbreak. 276 According to the Office of the Inspector General (OIG), only three inmates
were tested within two weeks of the transfer, and several exhibited symptoms of COVID-
19. 277 Upon arrival, 15 inmates tested positive, sparking the first cases at San Quentin.
Within three weeks, over 1,135 inmates and hundreds of staff were infected. By the end
of August 2020, the outbreak claimed the lives of 28 inmates and one staff member.
Similar transfers to Corcoran prison resulted in smaller outbreaks. 278
Poor adherence to health protocols within facilities exacerbated the spread. Limited
testing, outdated ventilation systems, and the congregate nature of prison spaces
created ideal conditions for transmission. Movement of inmates within housing blocks
intended for quarantine further spread the virus, as blocks often mixed uninfected
individuals with those who later tested positive. Resistance to testing and inconsistent
isolation practices also hindered containment efforts. Many inmates refused testing,
fearing relocation and disruptions to daily routines. Overcrowding complicated efforts
to separate individuals, while staff movement between housing blocks further
contributed to cross-contamination across facility sections. 279
Recommendation: Regularly update and enforce established protocols for inmate
transfers and infection control during public health emergencies.
• Align transfer protocols with current public health guidelines and limit transfers
to essential cases.
• Conduct health screenings before transfers, quarantine transferred inmates in
separate units and restrict movement between housing blocks for both
inmates and staff.
• Incorporate lessons from past outbreaks into staff training and emergency
plans to address operational challenges.
• Conduct drills and audits to test compliance with protocols and identify areas
for improvement.
276 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
277 OIG. "COVID-19 Review Series Part Three – Transfer of Patients from CIM." February 2021. Accessed December 9,
2024. https://www.oig.ca.gov/wp-content/uploads/2021/02/OIG-COVID-19-Review-Series-Part-3-%E2%80%93-
Transfer-of-Patients-from-CIM.pdf.
278 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
279 Stakeholder Interview
124
COVID-19 After Action Report
Chapter 7: Correctional Facilities
7.1.3 Correctional Facilities Outbreak
Strengths
Strength 2: A Unified Command Center at San Quentin was established to coordinate
custody and medical responses to COVID-19 cases as part of the response
infrastructure.
In June 2020, San Quentin Between May 28 and May 30, 2020, CCHCS and
medical leadership, Marin departmental management transferred 189 inmates,
County of Public Health, including many with underlying health conditions, to
CDPH COVID Response Corcoran and San Quentin to protect them from infection.
Team, and Deputy of Upon arrival at San Quentin, nursing staff immediately
Consultation CCHCS identified individuals exhibiting COVID-19 symptoms. 280 At
drafts a letter that states: the time, San Quentin had no reported infections, and
“…urgently Corcoran had just one case. However, within three weeks,
recommended and
San Quentin recorded 499 cases, and Corcoran reported
requested escalation of
148 cases. 281
the response to the
impending public health
To manage the outbreak, the state established a Unified
and humanitarian
disaster. The rate and
Command Center at San Quentin in June 2020. 282 The
penetration of COVID-19 center comprised experts from agencies including CDCR,
infections, combined with CCHCS, Cal OES, EMSA, CDPH, and Cal/OSHA. With
unique challenges at the additional support from the University of California, the
institution itself, are command center coordinated custody and medical
beyond the scope of responses. 283
what has been seen
before.” The state established a dedicated COVID-19 ward at San
Quentin to treat infected inmates, reducing the need for
transportation and mitigating security concerns. 284 EMSA deployed 24/7 response teams
to transfer inmates to regional medical facilities, alleviating pressure on San Quentin staff
and local ambulance services.
280 OIG. "COVID-19 Review Series Part Three – Transfer of Patients from CIM." February 2021. Accessed December 9,
2024. https://www.oig.ca.gov/wp-content/uploads/2021/02/OIG-COVID-19-Review-Series-Part-3-%E2%80%93-
Transfer-of-Patients-from-CIM.pdf.
281 Berkley Public Health. “COVID-19 Outbreak: San Quentin Prison.” June 15, 2020. Accessed December 9, 2024.
https://amend.us/wp-content/uploads/2020/06/COVID19-Outbreak-SQ-Prison-6.15.2020.pdf.
282 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
283 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
284 CDCR. “Joint Incident Action Plan COVID-19 Operational Period 05.0 9.2020.”
125
COVID-19 After Action Report
Chapter 7: Correctional Facilities
Simultaneously, CCHCS appointed a licensed healthcare clinician to implement
outbreak management strategies for both staff and inmates. 285 To improve hygiene and
minimize transmission risks, CDCR partnered with a cleaning vendor to perform a four-
day deep clean of institutions, secured additional contracts for laundry and trash
disposal services, and enhanced sanitation efforts. 286
Following these measures, the state activated an IMT at San Quentin to oversee
infection prevention, testing, and inmate care. CDCR and CCHCS directed all
institutions to activate their Incident Command Posts to further streamline responses. 287
In addition, the Board of State and Community Corrections allocated $15 million in
emergency COVID-19 funds to CDCR on July 16, 2020, to address housing needs for
individuals being released from prison. By July 30, 2020, the incarcerated population in
California correctional facilities fell below 100,000 for the first time in three decades,
reaching 99,929 inmates. 288
Strength 3: The Incident Management Team implemented infection prevention and
control measures at San Quentin, establishing a blueprint for COVID-19 response at
correctional facilities statewide.
During the summer of 2020, the IMT at San Quentin implemented infection prevention
and control measures, establishing a model for COVID-19 responses in correctional
facilities statewide. 289 CDPH and CDCR introduced COVID-19 lab result tracking for all
institution staff, enabling the IMT to identify new cases and monitor outbreak trends
through a centralized database. 290
The IMT developed a comprehensive medical plan for private medical contractor staff,
incorporating testing requirements and movement limitations. It conducted extensive
training for staff and inmates on COVID-19 safety protocols, emphasizing social
distancing, infection prevention, and equitable PPE distribution. Collaborating with
private medical contractors, the IMT designed detailed procedures for feeding,
sleeping arrangements, and infection control. 291 On July 10, 2020, the IMT established a
285 CDCR. “Joint Incident Action Plan Operational Period 07.08.2020 to 07.09.2020.” July 6, 2020.
286 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
287 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
288 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
289 Stakeholder interview
290 Cal OES SOC. “Joint Incident Action Plan Operational Period 07-04-2020 to 07-05-2020.” July 3, 2020.
291 CDCR. “Joint Incident Action Plan Operational Period 07.08.2020 to 07.09.2020.” July 6, 2020.
126
COVID-19 After Action Report
Chapter 7: Correctional Facilities
250-bed ACS within San Quentin, working with EMSA to coordinate operations with local
medical health and EMS coordinators. 292
After stabilizing the situation, the IMT created a transition plan to demobilize non-
CDCR/CCHCS personnel. This included establishing structures to support social
distancing, assigning housing based on COVID-19 status, and creating a
communication plan to keep staff and inmates informed about response activities. 293
Efforts extended to securing housing for positive inmates, providing recreational
facilities, and ensuring logistical support such as shipping essential packages. Transition
plans also contained training and fit testing to ensure preparedness. 294,295
Area for Improvement and Recommendations
Area for Improvement 2: Infrastructure and operational limitations at San Quentin
contributed to an outbreak.
San Quentin’s mid-19th century design and aging infrastructure were ill-suited for
managing a health crisis of this scale. 296 Its tightly packed cells, communal spaces, and
outdated ventilation system made social distancing impossible and failed to mitigate
the spread of airborne viruses. 297 Overcrowding exacerbated these challenges,
creating an environment conducive to viral transmission. 298
The prison’s limited medical facilities were unprepared for mass testing, isolation, and
treatment, becoming quickly overwhelmed by the surge in cases. This led to delays in
outbreak response and containment. The lack of clear guidance or established
protocols further hindered efforts to manage testing, quarantine, and shared space
usage, resulting in rapid virus transmission among inmates and staff. 299
292 CDCR. “Joint Incident Action Plan Operational Period 07.07.2020 to 07.08.2020.” July 6, 2020.
293 CDCR. “Joint Incident Action Plan Operational Period 07.22.20 to 07.23.20.” July 21, 2020.
294 CDCR.” Joint Incident Action Plan Operational Period 08.20.20 to 08.22.20.” August 19,2020.
295 CDCR. “Joint Incident Action Plan Operational Period 07.28.20 to 07.29.20.” July 27,2020.
296 Stakeholder Interview
297 CalPROTECT. “California State Prisons During the COVID-19 pandemic.” May 1, 2022. Accessed December 9,
2024. https://s3.amazonaws.com/cms.ipressroom.com/401/files/202308/2022-0501-CalPROTECT-Report.pdf.
298 CalPROTECT. “California State Prisons During the COVID-19 pandemic.” May 1, 2022. Accessed December 9,
2024. https://s3.amazonaws.com/cms.ipressroom.com/401/files/202308/2022-0501-CalPROTECT-Report.pdf.
299 Stakeholder Interview
127
COVID-19 After Action Report
Chapter 7: Correctional Facilities
Recommendation: Modernize state correctional facilities and address any deficiencies
in its infrastructure, focusing on redesigning communal areas, improving ventilation
systems, and enhancing overall facilities.
• Develop a capacity management plan to ensure the prison population aligns
with its design capacity, allowing effective social distancing.
• Upgrade the ventilation systems to meet modern health and safety standards,
reducing the risk of airborne virus transmission.
• Enhance medical facilities to accommodate mass testing, isolation, and
treatment requirements.
• Redesign communal areas to reduce crowding and improve infection
prevention measures.
7.2 Safety Measures
The state implemented protective measures in correctional facilities to reduce COVID-
19, including routine testing, vaccinations, PPE distribution, and selective inmate
transfers. The state also expanded on-site testing and established vaccine PODs.
Correctional facilities grappled with the unique complexities of managing large
populations in confined spaces and ensuring the health of both inmates and staff. In
response, the TTF organized testing efforts and formed the Corrections Cohort, later
known as the Corrections TTF. Despite widespread testing, logistical constraints,
compliance fatigue, and communication barriers highlighted the need for improved
planning in future public health emergencies.
128
COVID-19 After Action Report
Chapter 7: Correctional Facilities
7.2.1 Guidance
Strength
Strength 4: The state issued health guidance and enacted new safety measures using a
data-informed approach.
CDCR developed a COVID-19 Tracking Tool to monitor
positive cases and other data points across the
correctional system. The tracker, publicly available on
CDCR’s website, allowed families and staff to stay
informed. CDCR leadership used the tracker to guide
decisions about health protocols and resource
allocation. Once vaccines became available, CDCR
Figure 42. Screenshot of the CDCR
used the tracker to oversee vaccine distribution and COVID-19 Vaccination Tracker.
administration. 300 Source: CDCR website.
In March 2020, CDCR released a series of memos
addressing health and safety protocols for staff, inmates, and visitors. Topics included
PPE usage, precautions for transferring COVID-19-positive patients, hygiene protocols,
visitor self-screening, and testing requirements for those entering correctional facilities. 301
On April 2, 2020, CDCR launched an internal COVID-19 patient registry to assist
institutions in tracking patients with suspected or confirmed COVID-19. This registry also
monitored individuals by risk factors, drawing from multiple data sources, including
electronic health records and claims data. 302 The registry included release dates for
individuals considered for early release during the pandemic. CDCR restricted access
to the registry to protect personal health information. 303
300 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
301 CDCR. “Update to visiting regulations.” February 2, 2023. Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/update-to-visiting-regulations-2/.
302 CDCR. “COVID-19 Response Efforts.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/covid-19-
response-efforts/.
303 CDCR. “COVID-19 Response Efforts.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/covid-19-
response-efforts/.
129
COVID-19 After Action Report
Chapter 7: Correctional Facilities
Area for Improvement and Recommendations
Area for Improvement 3: Changing guidance led to low compliance among staff and
inmates.
CDCR encountered difficulties enforcing protective measures consistently across
approximately 100,000 inmates in various facilities. 304 Evolving state guidance frustrated
staff and inmates, eroding adherence to directives. 305
Correctional staff often neglected to comply with masking requirements, resulting in
multiple Cal/OSHA citations for improper mask fit testing. 306 As the pandemic
progressed, inmates expressed distrust toward state policies due to inconsistent
messaging, leading many to refuse testing, quarantine, and isolation while disregarding
masking and social distancing requirements. 307
Staff responsible for enforcing compliance struggled to perform their duties. A survey by
the OIG found that 31% of staff observed noncompliance with masking and 38% noted
issues with social distancing. Stakeholders reported that correctional staff felt
unsupported by CDCR leadership, who they believed failed to address their concerns
or proactively clarify evolving guidance and combat misinformation. 308
Recommendation: Develop a clear, consistent communication plan to promote
compliance with protective measures.
• Provide regular, clear communication with staff and inmates to reinforce the
importance of protective measures.
• Implement comprehensive educational programs to address the significance
of health measures and dispel misconceptions.
• Establish an open forum for dialogue between CDCR leadership and staff to
address concerns and clarify directives.
• Support correctional staff with tools and training to effectively enforce
compliance with health protocols.
304 CDCR. “COVID-19 Timeline.” Accessed December 9, 2024. https://www.cdcr.ca.gov/covid19/updates/.
305 Stakeholder Interview
306 SEIU Local 1000. “CDCR/CCHCS Continues to Ignore Legal Requirements With its COVID N95 Mask Mandates.”
January 11, 2022. Accessed December 9, 2024. https://www.seiu1000.org/post/cdcrcchcs-continues-ignore-legal-
requirements-its-covid-n95-mask-mandates.
307 OIG. “COVID-19 Review Series Part Two.” October 2020. Accessed December 9, 2024.
https://www.oig.ca.gov/wp-content/uploads/2020/10/OIG-COVID-19-Review-Series-Part-2-%E2%80%93-Face-
Coverings-and-PPE.pdf.
308 Stakeholder Interview
130
COVID-19 After Action Report
Chapter 7: Correctional Facilities
7.2.2 Visitation
Area for Improvement and Recommendations
Area for Improvement 4: Changes in the state's guidance delayed the implementation
of updated protocols, particularly the cancellation of in-person visitation, which
prevented family members from seeing loved ones in correctional facilities.
CDCR faced difficulties integrating rapidly evolving
guidance from federal and state authorities. This led to
delays in implementing updated protocols, creating
confusion among correctional staff and hesitancy in
enforcing conflicting guidelines. 309
On March 11, 2020, CDCR suspended in-person
visitation across all correctional facilities to reduce the
Figure 43. CDCR implemented virtual risk of COVID-19 transmission. While this decision aimed
visitation to assist with the limitation of in-
person visits during COVID-19. to protect inmates and staff, it generated significant
Source: CDCR Facebook. controversy among stakeholders. The cancellation
disconnected inmates from family members and
attorneys while reducing external oversight of facility conditions, including COVID-19
isolation units. 310 This lack of transparency sparked allegations that some facilities
neglected protective measures, increased solitary confinement, and denied inmates
access to essentials such as adequate food, water, outdoor time, sanitary supplies,
phone calls, and medical care. 311
Families of inmates consistently requested the resumption of visitation throughout the
pandemic. In response, CDCR introduced a virtual visitation program in December 2020,
providing inmates one free 30-minute video visit every 30 days. Initially rolled out to a
limited number of facilities, the program expanded to 35 facilities by the end of 2020,
reconnecting inmates with loved ones and offering some oversight of COVID-19
309 Stakeholder Interview
310 Stakeholder Interview
311 Stakeholder Interview
131
COVID-19 After Action Report
Chapter 7: Correctional Facilities
responses in correctional facilities. 312 Limited in-person visitation resumed in April 2021 but
was periodically suspended at individual facilities in response to new outbreaks. 313
Despite these efforts, corrections stakeholders identified gaps in communication. CDCR
lacked consistent messaging about policy changes to inmates, their families, and the
California Statewide Inmate Family Council (SIFC). The SIFC, a centralized advocacy
network for inmate families, was supposed to receive updates through quarterly
meetings. However, many 2020 meetings were canceled due to pandemic-related
challenges, leaving the SIFC without adequate information to share with families. 314
Recommendation: Develop a comprehensive communications plan to support timely
updates on visitation policy changes.
• Include transparent mechanisms for reporting the reasoning behind visitation
policy changes to inmates and families.
• Establish regularly scheduled meetings with advocacy groups like the SIFC for
consistent messaging and information sharing.
• Provide correctional staff with training and resources to support the
implementation of visitation policies and effective communication strategies.
7.2.3 Corrections Testing Task Force
Strength
Strength 5: The Testing Task Force played a critical role in organizing and implementing
testing in correctional facilities across the state, addressing the unique challenges
posed by these high-risk environments.
The TTF established the Corrections TTF to manage testing operations within correctional
facilities, forming an Outbreak Response Team to provide testing access at over 1,150
sites, including jails and prisons. 315 The team tailored state testing protocols to address
the confined and high-density conditions of correctional facilities, prioritizing rapid test
turnaround times. Real-time feedback and evolving needs informed continuous
312 Office of the Governor. “Governor Newsom Issues Executive Order on State Prisons and Juvenile Facilities in
Response to the COVID-19 Outbreak.” March 24, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/03/24/governor-newsom-issues-executive-order-on-state-prisons-and-juvenile-
facilities-in-response-to-the-covid-19-outbreak/.
313 Office of the Governor. “Governor Newsom Issues Executive Order on State Prisons and Juvenile Facilities in
Response to the COVID-19 Outbreak.” March 24, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/03/24/governor-newsom-issues-executive-order-on-state-prisons-and-juvenile-
facilities-in-response-to-the-covid-19-outbreak/.
314 Stakeholder Interview
315 CDPH. “COVID-19 AAR – Testing.” July 2024.
132
COVID-19 After Action Report
Chapter 7: Correctional Facilities
improvements to protocols, targeting high-risk areas to effectively prevent and contain
outbreaks. 316
The Corrections TTF conducted analyses to identify high-risk areas and directed
resources and personnel accordingly to sustain operations. Working closely with CDCR
and other state agencies, the Corrections TTF oversaw the administration of over 24,000
COVID-19 tests across correctional sites, demonstrating the effectiveness of the
initiative. 317
The state implemented a unified communication strategy to streamline testing
operations and provide consistent messaging. The Corrections TTF and CDCR
developed testing schedules and protocols, establishing fixed testing sites, deploying
mobile units, and engaging over 250 California National Guard members to expand
capacity during peak demand. 318
By integrating testing into daily correctional facility operations, the state minimized
disruptions while maintaining logistics and staffing. 319 Mobile testing teams and
established procedures ensured consistent testing coverage across facilities, providing
an effective response to ongoing challenges in high-risk environments. 320
Area for Improvement and Recommendations
Area for Improvement 5: The demand for testing revealed a lack of adequate strategy
to address the unique needs of correctional environments.
Rapid expansion of testing programs revealed challenges such as delays in distributing
testing supplies and equipment. Physical constraints within correctional facilities
complicated the setup of testing sites, disrupting testing flow and reducing efficiency.
Compliance fatigue among staff and inmates further undermined quarantine and
testing measures, complicating outbreak management. Inmate relocations to control
outbreaks added to the workload and reduced adherence to testing and mask
mandates. 321
While the state coordinated efforts between agencies and correctional facilities,
demand for testing occasionally outpaced available resources. Diverse needs and
316 CDPH. “COVID-19 AAR – Testing.” July 2024.
317 CDPH. “COVID-19 AAR – Testing.” July 2024.
318 CDPH. “COVID-19 AAR – Testing.” July 2024.
319 CDPH. “COVID-19 AAR – Testing.” July 2024.
320 CDPH. “COVID-19 AAR – Testing.” July 2024.
321 Stakeholder Interview and Stakeholder Hotwash
133
COVID-19 After Action Report
Chapter 7: Correctional Facilities
operational capacities across facilities resulted in inconsistencies in testing
implementation. Communication barriers and the absence of standardized protocols
hindered effective integration of testing operations. 322
Recommendation: Establish standardized protocols for testing procedures across all
correctional facilities to achieve consistency and efficiency. Include guidelines for
setting up testing sites, managing physical space, and handling testing equipment.
• Tailor testing and quarantine procedures to accommodate different facility
sizes, layouts, and inmate populations.
• Enhance communication channels between state agencies and correctional
facilities to improve coordination and resource allocation.
• Develop strategies to manage inmate relocations during outbreaks,
maintaining testing and quarantine measures throughout the process.
7.3 Inmate Release
To mitigate the spread of COVID-19 and reduce overcrowding in correctional facilities,
the state implemented an early release program for eligible inmates, allowing them to
return to their communities ahead of schedule. This initiative supported social distancing
measures and prioritized protecting individuals at higher risk of severe outcomes.
Released individuals exposed to COVID-19 could access the state’s Project Hope
program, which provided temporary housing for isolation or quarantine.
7.3.1 Release Program
Strength
Strength 6: California Department of Corrections and Rehabilitation expedited the
release of almost 3,500 inmates serving sentences for non-violent offenses to reduce the
risk of mass outbreaks in correctional facilities.
Correctional facilities were inherently ill-suited for social distancing due to their design,
which housed inmates in close quarters. This environment heightened the risk of disease
transmission and challenged staff in implementing effective quarantine measures. 323
322 CDPH. “COVID-19 AAR – Testing.” July 2024.
323 CDCR. “Actions to Reduce Population and Maximize Space.” Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/frequently-asked-questions-expedited-releases/.
134
COVID-19 After Action Report
Chapter 7: Correctional Facilities
In April 2020, CDCR implemented an early release program expediting the release of
almost 3,500 individuals incarcerated in state prisons. 324 The program prioritized inmates
serving non-violent sentences who had fewer than 60 days remaining and were not
registered sex offenders. By July 2020, eligibility expanded to include inmates with up to
180 days remaining on their sentences, allowing for further reductions in prison
populations. 325
To encourage compliance and good behavior, CDCR awarded 12 weeks of positive
programming credit to inmates with no rule violations between March 1 and July 5, 2020.
Additionally, medically high-risk inmates were assessed for potential release on a case-
by-case basis to protect their health. 326
By July 2021, the program had successfully reduced prison density and contributed to
lower COVID-19 rates within correctional facilities. Stakeholders emphasized the
program's effectiveness in minimizing outbreaks while balancing public safety. 327
7.3.2 Project Hope
Strength
Strength 7: Project Hope offered complimentary hotel accommodations to facilitate
isolation and quarantine for thousands of individuals recently released from
incarceration, reducing community exposure and alleviating pressure on correctional
facilities.
In April 2020, CDCR partnered with state and local agencies to launch Project Hope,
offering complimentary hotel and motel accommodations to newly released individuals
requiring isolation or quarantine. Participants could safely separate from others,
mitigating potential viral transmission to their families and communities.
The program was voluntary but required participants to adhere to CDCR safety rules. It
included transportation, meal services, and accommodations, which were organized in
collaboration with local partners. Addressing logistical challenges, CDCR treated every
324 CDCR. “Actions to Reduce Population and Maximize Space.” Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/frequently-asked-questions-expedited-releases/.
325 CDCR. “Actions to Reduce Population and Maximize Space.” Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/frequently-asked-questions-expedited-releases/.
326 CDCR. “Actions to Reduce Population and Maximize Space.” Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/frequently-asked-questions-expedited-releases/.
327 CDCR. “Actions to Reduce Population and Maximize Space.” Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/frequently-asked-questions-expedited-releases/.
135
COVID-19 After Action Report
Chapter 7: Correctional Facilities
individual released as a potential COVID-19 patient, helping ensure seamless
coordination and reducing pressure on correctional facilities.
By May 2022, Project Hope had served approximately 2,000 individuals, providing
essential support during their transition. Additionally, around 1,100 individuals who were
ineligible for Project Hope were referred to CDCR-funded programs for continued
assistance. 328
328 CDCR. “CDCR Week in Review: May 27, 2022.”
136
COVID-19 After Action Report
Chapter 8: Education
CHAPTER 8: EDUCATION
CHAPTER INTRODUCTION
The COVID-19 pandemic disrupted learning for an entire generation of students,
disproportionately impacting people with lower incomes, less robust support systems,
and fewer economic advantages. Educational institutions, as congregate settings,
faced higher risks of virus transmission. To protect public health, the state implemented
orders to close in-person learning.
By March 2020, over 99 percent of the state’s 6.2 million public school students were
affected by closures, with 939 of 1,035 local educational agencies (LEAs) transitioning
to distance learning. 329 Colleges and universities also adopted virtual learning, closing
dormitories and residential halls. This shift required schools to adopt new technologies
and strategies to maintain educational services.
Distance learning exposed disparities in instructional
quality, technological access, and essential services
often provided by schools. Executive Order N-26-20
directed districts to use state funds for distance
learning, high-quality education, and school meal
programs. Executive Order N-73-20 supported efforts
to bridge the digital divide by equipping students with
devices and connectivity.
Figure 36. Closing the Digital Divide logo.
Source: CDE website. The state prioritized reopening schools safely. Initial
guidance in June 2020 outlined plans for resuming in-
person instruction. In December 2020, the Safe Schools for All Plan emphasized testing
and vaccination as key strategies for maintaining safe learning environments. 330
As critical infrastructure, schools faced severe challenges during the pandemic.
Increased coordination between K-12 institutions and the state can enhance disaster
resilience. Lessons learned from the pandemic will strengthen California’s educational
system for future emergencies.
329 California School Boards Association. “COVID-19 closes nearly every California school.” April 2020. Accessed
December 9, 2024. https://publications.csba.org/california-school-news/april-2020/covid-19-closes-nearly-every-
california-school/.
330 Office of the Governor. “Governor Newsom Unveils California’s Safe Schools for All Plan.” December 30, 2020.
Accessed December 9, 2024. https://www.gov.ca.gov/2020/12/30/governor-newsom-unveils-californias-safe-
schools-for-all-plan/.
137
COVID-19 After Action Report
Chapter 8: Education
State Education Priorities
Public Health Measures
• Implemented school closures to mitigate the spread of the virus by limited in-
person instruction.
• Communicated safety guidelines to educators, parents, and students.
• Distributed PPE to staff and students of LEAs/Institutions of Higher Education
(IHEs) to support the physical reopening of school sites.
• Deployed testing resources at schools to identify and isolate cases early,
during phased reopening.
• Phased reopening of schools through strict safety protocols.
• Prioritized vaccination of teachers, school staff, and eventually students.
Educational Adaptations
• Evaluated hybrid learning models to balance education and safety.
• Provided devices, internet access, and digital learning support for students
and educators.
• Investigated and assisted with connectivity issues in rural and frontier areas of
the state.
Adaptive Response Strategies
• Monitored and adapted to changing infection rates and government
guidelines.
• Continued to adapt and refine response strategies based on the evolving
science.
• Improved communication between the CDE and county offices of education.
FINDINGS
This chapter examines the state's support for education during crises, focusing on
educational coordination and health and safety measures. The Educational
Coordination section highlights efforts to maintain learning continuity and foster
effective collaboration among institutions. The Health and Safety Measures section
reviews initiatives aimed at protecting students, educators, and staff.
8.1 Educational Coordination
In collaboration with Cal OES, CDE, and other agencies, the Schools Task Force
monitored pandemic impacts on education and facilitated information sharing among
systems. The Task Force supported the Safe Schools for All plan, focusing on PPE
138
COVID-19 After Action Report
Chapter 8: Education
distribution, direct ordering systems, and technological resources for LEAs, which include
school districts, county education offices, charter schools, and IHEs.
CDE handled educational aspects independently, maintaining daily coordination with
government and professional education organizations. A key focus was improving
technology accessibility.
In December 2020, as schools began reopening, the state launched a Cabinet-Level
Education Task Force led by the State Superintendent and a State Senator. This high-
level group collaborated with the State Public Health Officer to develop policies for
activities such as the Safe Schools for All Hub and PPE distribution. 331
8.1.1 Schools Task Force and Cabinet-Level Education Task Force
Strengths
Strength 1: The Cabinet-Level Schools Task Force bridged the digital divide by
connecting up to one million students to technology resources.
The Cabinet-Level Schools Task Force, led by the State
Superintendent, coordinated efforts with CDE, state
officials, and private partners to eliminate disparities in
technology access. This collaboration included
partnerships with internet providers, tech companies,
and device manufacturers, enabling the delivery of
essential technology resources like discounted iPads
equipped with high-speed internet. These partnerships
directly addressed barriers to distance learning. Figure 37. Technology devices being
dispersed by a staff member at a
California school. Source: CDE
This initiative aligned with a $5.3 billion state budget Facebook.
allocation for distance learning. It expedited the
acquisition of devices and internet access, helping students and educators transition to
remote learning. 332 For example, Apple provided iPads with cellular capability and
training for educators, while T-Mobile expanded internet access to connect students. By
the end of 2020, these efforts provided essential technology resources to nearly one
million students, significantly reducing disparities in distance learning access. 333
330 Live Edit Session 331 CDE. “State Superintendent Tony Thurmond Announces Major Collaboration with Apple and
T-Mobile to Connect Students in Need.” August 5, 2020. Accessed December 9, 2024.
https://www.cde.ca.gov/nr/ne/yr20/yr20rel65.asp.333 CDE. “State Superintendent Tony Thurmond Announces Major
Collaboration with Apple and T-Mobile to Connect Students in Need.” August 5, 2020. Accessed December 9, 2024.
https://www.cde.ca.gov/nr/ne/yr20/yr20rel65.asp.
139
COVID-19 After Action Report
Chapter 8: Education
Guided by the Task Force, school districts placed orders with private partners, securing
at least 100,000 devices for distribution during the back-to-school period. Commitments
from partners ensured districts received additional devices throughout 2020, reducing
technological disparities for 97 percent of California students engaged in distance
learning. 334
Strength 2: The Schools Task Force facilitated the distribution and direct ordering of
personal protective equipment to educational institutions for the safe return to in-person
instruction.
In collaboration with the Logistics and Commodities Movement Task Force, the Schools
Task Force distributed tens of millions of essential PPE items, including cloth masks, face
shields, goggles, gowns, and coveralls, to support the safe return of students and staff
to schools. 335 In January 2022 alone, the state distributed over 30 million N95 respirators,
KN95 masks, and children's surgical masks to county Boards of Education within two
weeks of schools reopening, demonstrating the speed and scale of the effort. 336
Initially, the Schools Task Force utilized a "push down" distribution approach, sending PPE
to Local Educational Agencies (LEAs) without receiving specific requests. While this
method expedited distribution, it overlooked the unique needs of individual districts. In
response, the state transitioned to a request-based system, granting county Boards of
Education and IHEs access to Salesforce Public Health Ordering System accounts. This
shift allowed schools to customize their PPE orders to fit their needs.
Area for Improvement and Recommendations
Area for Improvement 1: There were multiple task forces for Education, creating
challenges in implementing directives.
The Schools Task Force and the Cabinet Level Education Task Force faced
communication and coordination challenges during the reopening process. Policy
discussions regarding school reopening planning did not include all stakeholders.
Members expressed frustration, emphasizing that their hands-on experience offered
334 CDE. “State Superintendent Tony Thurmond Announces Major Collaboration with Apple and T-Mobile to
Connect Students in Need.” August 5, 2020. Accessed December 9, 2024.
https://www.cde.ca.gov/nr/ne/yr20/yr20rel65.asp.
335 ICS 202 Task Force Priorities and Objectives.
336 Cal OES News. “Cal OES has Distributed Over 1.6 Billion Pieces of PPE to Californians.” January 31, 2022.
Accessed December 9, 2024. https://news.caloes.ca.gov/cal-oes-has-distributed-over-1-6-billion-pieces-of-ppe-to-
californians/.336 Live Edit Session
140
COVID-19 After Action Report
Chapter 8: Education
critical insights into school-level realities that could have informed more practical and
effective policies. 337
Without valuable input from those directly involved in execution, policies often failed to
consider real-world scenarios, resulting in implementation difficulties and a lack of
alignment with the needs and conditions of local schools. 338 For example, in December
2020, as part of the State Safe Schools for All Plan—California’s framework for safely
resuming in-person instruction—the Governor’s Office allocated funds for PPE
distribution to all schools. However, the Schools Task Force was not consulted during this
planning phase. This oversight bypassed the task force’s knowledge of execution
challenges, complicating PPE distribution efforts. 339
Over time, communication between the two task forces improved, enhancing
coordination and collaboration on subsequent initiatives.
Recommendation: Establish policy and procedures to align Task Force objectives and
achieve consistent results.
• Develop a plan to regularly align objectives and responsibilities among task
forces with overlapping priorities.
• Organize joint planning sessions involving members from all relevant task forces
to facilitate comprehensive policy creation.
• Implement regular communication mechanisms between task forces to
enhance information sharing and coordination.
• Actively involve educators and school representatives in policy discussions to
ensure practical and actionable strategies.
8.1.2 Information Sharing
Strength
Strength 3: The school reporting system improved information-sharing capabilities
between state and local educational agencies.
In August 2021, the state developed the School Emergency Reporting System (SERS), a
web-based application that enhanced the exchange of critical information between
the state and LEAs during natural disasters and other urgent incidents. 340 SERS allowed
LEAs to report COVID-19 outbreaks, enabling real-time tracking and response efforts.
338 Live Edit Session
339 Live Edit Session
340 Stakeholder Interview
141
COVID-19 After Action Report
Chapter 8: Education
The system served as a centralized database, providing LEAs with up-to-date
information on outbreaks and closures statewide. Designed with user-friendly interfaces,
SERS simplified data entry, reducing manual errors through automated reporting
features. It also incorporated advanced security measures to protect the privacy of
health-related information. Authorized LEA personnel received training and support to
maximize the system's effectiveness, ensuring it became a valuable tool for coordinated
response efforts. 341
8.2 Health and Safety Measures
The state implemented a range of policies, executive orders, and initiatives to address
health and safety in schools during the pandemic. These efforts supported LEAs through
funding allocations, testing programs, contact tracing initiatives, and vaccination
campaigns. This section examines the measures taken to facilitate safe in-person
instruction, sustain learning opportunities, and protect students, staff, and their families.
8.2.1 Educational Guidance
Strengths
Strength 1: A series of government directives supported local educational agencies
during the COVID-19 crisis.
In March 2020, the state took decisive action to address school closures triggered by
stay at home orders. On March 13, 2020, Executive Order N-26-20 maintained state
funding for LEAs, including school districts, county education offices, and charter
schools. This funding supported distance learning, school meal programs like the
Summer Food Service Program, student supervision during regular hours, and employee
payments. 342
Shortly after, on March 17, 2020, Senate Bill 117 allocated $100 million to LEAs for
purchasing PPE and covering cleaning costs related to COVID-19 in school facilities. 343
This ensured LEAs remained funded even as closures continued. The same day, the CDE
released COVID-19 closure guidance covering three key areas: distance learning,
school meals, and childcare supervision. School closures impacted over 99% of the
341 CDE. “New School Emergency Reporting System” August 31, 2021. Accessed December 9, 2024.
https://www.cde.ca.gov/nr/el/le/yr21ltr0831.asp.
342 Executive Order N-26-20
343 California School Boards Association. “COVID-19 closes nearly every California school.” April 2020. Accessed
December 9, 2024. https://publications.csba.org/california-school-news/april-2020/covid-19-closes-nearly-every-
california-school/.
142
COVID-19 After Action Report
Chapter 8: Education
state’s 6.2 million public school students, with nearly 939 out of 1,035 LEAs closing or
preparing to close. 344
Under Executive Order N-26-20, multiple agencies,
including CDE and CalHHS, were tasked with issuing
guidance by March 27, 2020 on implementing distance
learning strategies, improving internet access,
providing education for students with disabilities, and
distributing meals. 345 The Labor and Workforce
Development Agency and CalHHS issued parent
Figure 38. Meals being safely distributed
support guidance, while the Governor’s Office of
to students by staff at a California Business and Economic Development worked with
school. Source: CDE Facebook. businesses to foster flexible employer policies for
parents. 346 These directives, alongside efforts by public
health staff, emergency managers, and responders, supported PPE distribution, testing,
vaccination, mental health services, hygiene practices, and distance learning
resources. 347
Strength 2: The Safe Schools for All Plan facilitated the safe resumption of in-person
instruction in schools.
In December 2020, the Governor’s Office released the Safe Schools for All Plan, outlining
a framework for resuming in-person instruction. The plan was built on four key pillars:
• Funding to Support Safe Reopening: The January 2021 Budget allocated $2
billion to support testing, ventilation improvements, and PPE provision for
schools resuming in-person instruction or planning phased reopening. 348
• Safety & Mitigation Measures for Classrooms: Mitigation strategies included
frequent COVID-19 testing for students and staff, weekly testing in high-
transmission areas, and distribution of millions of surgical masks to school
personnel. Vaccination of school staff was also prioritized.
• Hands-on Oversight & Assistance for Schools: The Safe Schools for All team, led
by a pediatric expert and school safety specialist, provided direct support to
schools. This included developing COVID-19 safety plans, conducting
webinars, organizing training, and delivering ongoing technical assistance.
344 California School Boards Association. “COVID-19 closes nearly every California school.” April 2020. Accessed
December 9, 2024. https://publications.csba.org/california-school-news/april-2020/covid-19-closes-nearly-every-
california-school/.
345 Executive Order N-26-20
346 Executive Order N-26-20
347 Stakeholder Interview
348 California Department of Finance. “Governor's Budget Summary 2021-22.” January 2021. Accessed December
9, 2024. https://ebudget.ca.gov/2021-22/pdf/BudgetSummary/Introduction.pdf.
143
COVID-19 After Action Report
Chapter 8: Education
• Transparency and Accountability for Families and Staff: The Safe Schools for All
Hub, an online platform, offered families and staff access to information on
school reopening, available funding, and outbreak data. The hub included a
hotline allowing staff and parents to report concerns, initiating interventions
ranging from technical support to legal enforcement actions. 349
The plan introduced an interactive map to provide
real-time information on reopening and safety
measures. The state allocated over $90 billion to equip
schools with resources such as PPE and technical
support, emphasizing the importance of creating safer
learning environments for vulnerable student
populations. 350
Figure 39. CDPH Safe Schools for All
8.2.2 Contact Tracing advertisement. Source: CDPH website.
Strengths
Strength 3: California Connected provided technical assistance to educational
institutions on case investigation and contact tracing.
After Assembly Bill 86, the state delegated contact tracing responsibilities from
overwhelmed local health departments to K-12 schools. Schools had critical, real-time
information on student interactions, such as shared classrooms, carpools, and lunch
tables. 351
The Schools Support Team expanded its role within the California Connected program
to include schools as a key customer base. Leveraging its existing network, the program
scaled up to aid schools, coaching districts on contact tracing strategies.
Communication channels established with school districts and administrators helped
identify necessary resources. The team also developed documentation, websites,
newsletters, and webinars tailored to school administrators to support tracing efforts. 352
349 Office of the Governor. “Governor Newsom Unveils California’s Safe Schools for All Plan.” December 30, 2020.
Accessed December 9, 2024. https://www.gov.ca.gov/2020/12/30/governor-newsom-unveils-californias-safe-
schools-for-all-plan/.
350 Office of the Governor. “California Launches Interactive Map as Part of Safe Schools for All Plan.” February 12,
2021.Accessed February 12, 2021. https://www.gov.ca.gov/2021/02/12/california-launches-interactive-map-as-
part-of-safe-schools-for-all-plan/.
351 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
352 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
144
COVID-19 After Action Report
Chapter 8: Education
Strength 4: The Virtual Training Academy introduced school-related contact tracing
courses in response to school reopening.
The VTA adapted to meet the needs of schools, offering specialized training to support
safe reopening. Courses included topics such as pediatric COVID-19 basics, effective
communication with school districts, and triaging questions to local health departments.
The VTA also provided training in risk communication and safe school protocols for K-12
administrators.
To reach under-resourced schools in rural districts, the Schools Support Team
collaborated with external stakeholders to promote training opportunities. From its
inception through October 2022, over 11,000 learners completed VTA courses,
equipping them with skills necessary to manage contact tracing in educational
settings. 353
8.2.3 Schools Testing Task Force
Strength
Strength 5: The Testing Task Force established and managed COVID-19 testing in
California's K-12 schools, providing broad access and effective resource distribution.
To meet the unique challenges of educational environments, the TTF created the
Schools Testing Task Force (Schools TTF) as a specialized subgroup. The Schools TTF
offered a range of testing options, including PCR and antigen tests for schools, and
developed resources such as playbooks, training materials, and operational
guidance. 354
The Schools TTF prioritized supply distribution, providing protective equipment and
testing materials essential for maintaining safe school environments. 355 Over 4,700 school
testing sites were established statewide, making it widely accessible to students and
staff. 356 Additionally, the Schools TTF coordinated with other state agencies to redirect
staff and assist schools with resourcing sites, reducing the operational burden on school
staff.
Nearly 1,000 K-12 schools across 120 school districts received comprehensive vendor
support during the 2021–2022 school year. This included antigen, PCR, and pooled PCR
testing, ensuring efficient operations with minimal disruption to educational processes.
353 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
354 CDPH. “COVID-19 AAR – Testing.” July 2024.
355 Stakeholder Hotwash
356 CDPH. “COVID-19 AAR – Testing.” July 2024.
145
COVID-19 After Action Report
Chapter 8: Education
The Schools TTF facilitated the integration of PCR testing into schools by creating an
onboarding checklist, supplying consistent resources, and establishing clear enrollment
processes. Enrollment included setting up testing protocols, providing staff training, and
managing participation.
Historically, CDE developed emergency plans with limited collaboration with state
agencies during incident responses. By the end of 2021, however, the Schools TTF
successfully engaged CDE in state planning and response efforts. This included regular
planning meetings and direct involvement in decision-making processes for testing and
COVID-19 mitigation strategies. These efforts improved coordination and alignment
between state strategies and the needs of schools, leading to more effective
implementation of testing programs. 357
Area for Improvement and Recommendations
Area for Improvement 1: The pandemic's initial phases revealed significant challenges
in coordinating and communicating school testing operations.
Limited personnel and insufficient involvement from educational leaders led to
communication breakdowns and delays in delivering clear guidance to schools. 358
Multiple task forces addressing school-related issues created confusion, duplicated
efforts, and further delayed the implementation of testing
Collaboration gaps between the TTF and agencies like CDPH led to inconsistent
messaging and delays in resource allocation. The slow approval process for messaging
and website content resulted in outdated email communications, as information was
often replaced before messages were distributed, further hindering school
coordination. During the transition from PCR to antigen testing, the TTF failed to provide
clear guidance, leaving schools uncertain about new protocols and oversight
responsibilities. 359 Centralized decision-making failed to account for the needs of rural
schools and special education programs, leading to gaps in testing coverage and
support.
Although the TTF later introduced SERS to improve communication between LEAs and
CDE, the absence of a standardized incident management approach continued to
create barriers to effective testing operations.
357 Stakeholder Hotwash
358 Stakeholder Hotwash
359 Stakeholder Hotwash
146
COVID-19 After Action Report
Chapter 8: Education
Recommendation: Develop a statewide framework to improve coordination,
communication, and operational consistency for school testing efforts during
emergencies.
• Establish standardized reporting structures, workflows, and protocols for
schools to follow during testing operations.
• Create a centralized platform for real-time communication to provide schools
with timely updates on testing protocols and resources.
• Conduct regular training and exercises to improve collaboration and
readiness among schools, state agencies, and other key stakeholders.
8.2.4 Partnership and Collaboration
Strength
Strength 6: The Governor’s Office, California Department of Education, and Testing Task
Force improved collaboration during the pandemic, enhancing state support for schools
through lessons learned from past emergencies.
The partnership between the Governor’s Office, CDE, and the TTF evolved during the
pandemic, improving coordination and resource distribution. 360 The Schools TTF
leveraged existing systems, such as the County Superintendent Services Educational
Association (CSSEA), to streamline communication and coordination among county
superintendents. These established relationships facilitated efficient information sharing
and resource delivery at the local level. 361
The Schools TTF used the SERS platform to collect real-time data on school closures and
testing needs, supporting timely and informed decision-making. Operational support
prioritized underfunded schools, addressing equity challenges through direct funding
and comprehensive vendor services.
Collaboration deepened among the Governor’s Office, CDE, and the California State
Board of Education as they refined equity-driven processes and prioritized schools for
testing programs. 362 A dedicated Schools TTF team worked closely with CDE and
education stakeholders, adapting testing strategies to meet the evolving needs of
schools and maintaining consistent support throughout the pandemic. 363
360 CDPH. “COVID-19 AAR – Testing.” July 2024 and Stakeholder Interview
361 Stakeholder Interviews
362 CDPH. “COVID-19 AAR – Testing.” July 2024.
363 CDPH. “COVID-19 AAR – Testing.” July 2024.
147
COVID-19 After Action Report
Chapter 8: Education
8.2.5 Vaccinations
Strength
Strength 7: The School-located Vaccination Events made pediatric vaccines accessible
to 182 school sites across 36 school districts.
After the release of pediatric vaccine doses, the state launched the School-located
Vaccination Events in November 2021. This campaign expanded vaccine accessibility
for students aged five and older and their families, and resulted in the rapid
immunization of large numbers of children. 364
The state organized events at interested schools in
collaboration with mobile service providers. These
events were shaped to the preferences of each
school, with some focusing on students only and others
including families and community members. A total of
182 school sites across 36 school districts and 17 local
health jurisdictions hosted 371 vaccination events,
administering 13,549 doses. 365
Figure 40. State organized vaccine event
at a California school site.
Source: CDE Facebook. Using insights from CDE, the state designated staff to
oversee communication with school district and LEA
staff. The state shared marketing materials, deploying food trucks, and identified schools
needing additional media support. The use of incentives, particularly food trucks,
proved effective in increasing participation. 366
364 CDPH. “Resources for School-Located Vaccination Events.” Accessed December 9, 2024.
https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/School/resources-clinics.aspx#.
365 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
366 CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
148
COVID-19 After Action Report
Appendices
APPENDIX A: ACRONYMS
Table 3: Acronyms Table
Acronym Term
AAR After Action Report
ABC California Department of Alcoholic Beverage Control
ACS Alternate Care Site
ADA Americans with Disabilities Act
AFN Access and Functional Needs
ASL American Sign Language
BCSH California Business, Consumer Services, and Housing Agency
CAIR2 California Immunization Registry
CA-ESF California Emergency Support Function
CAL FIRE California Department of Forestry and Fire Protection
Cal OES California Governor’s Office of Emergency Services
Cal Volunteers California Volunteers
Cal/OSHA California Division of Occupational Safety and Health
CalCAT California Communicable Diseases Assessment Tool
CalHHS California Health and Human Services Agency
CAL-MAT California Medical Assistance Team
CalHR California Department of Human Resources
CalREDIE California Reportable Disease Information Exchange
Caltrans California Department of Transportation
CalWORKs California Work Opportunity and Responsibility to Kids
CAP Corrective Action Plan
CARES Coronavirus Aid, Relief, and Economic Security
CBO Community Based Organizations
CCHCS California Correctional Health Care Services
CDC Centers for Disease Control and Prevention
CDCR California Department of Corrections and Rehabilitation
CDE California Department of Education
CDPH California Department of Public Health
CDSS California Department of Social Services
CSSEA County Superintendent Services Educational Association
CSTI California Specialized Training Institute
CVAC Community Vaccine Advisory Committee
DGS California Department of General Services
DIR California Department of Industrial Relations
149
COVID-19 After Action Report
Appendices
DSH California Department of State Hospitals
EDD Employment Development Department
EMSA Emergency Medical Services Authority
EOC Emergency Operations Center
ESA Emergency Services Act
ESF Emergency Support Function
FDA U.S. Food and Drug Administration
FEMA Federal Emergency Management Agency
GO-Biz Governor's Office of Business and Economic Development
GovOps California Government Operations Agency
ICS Incident Command System
IHE Institutions of Higher Education
IHSS In-Home Support Service
IMT Incident Management Team
JIC Joint Information Center
JITT Just-in-Time Training
LEA Local Educational Agency
LTCF Long-term Care Facility
MHCC Medical and Health Coordination Center
MHOAC Medical Health Operational Area Coordinator
MRC Medical Reserve Corps
NGO Non-Governmental Organization
OA Operational Area
OAFN Office of Access and Functional Needs
OIG Office of the Inspector General
PCR Polymerase Chain Reaction
POD Point of Dispensing
PPE Personal Protective Equipment
PUA Pandemic Unemployment Assistance
SEMS Standardized Emergency Management System
SERS School Emergency Reporting System
SIFC Statewide Inmate Family Council
SNF Skilled Nursing Facility
SNS Strategic National Stockpile
SOC State Operations Center
SPB State Personnel Board
TPA Third-Party Administrator
TTF Testing Task Force
UCG Unified Coordination Group
150
COVID-19 After Action Report
Appendices
USDHHS U.S. Department of Health and Human Services
USNS United States Naval Ships
VBL Valencia Branch Lab
VTA Virtual Training Academy
WHO World Health Organization
APPENDIX B: REFERENCES
Table 4: Table of Internal References
Internal References
ABC. “Second Notice of Regulatory Relief.” April 1, 2020. Accessed December 9, 2024.
https://www.abc.ca.gov/abc-announces-that-bars-wineries-breweries-and-distilleries-
will-be-able-to-sell-drinks-to-go/.
BCSH. “COVID-19 Tenant Relief Act.” https://www.bcsh.ca.gov/covidrelief /.
BCSH. “Landlords – Protection Information.” Accessed December 9, 2024.
https://housing.ca.gov/landlord/protection_guidelines.html#:~:text=Many%20landlord
s%20have%20also%20felt,AB%20832%2C%20provides%20some%20relief.
CalHR. “Contact Tracer Assignment Information for State Departments.” May 28, 2020.
Accessed December 9, 2024. https://www.calhr.ca.gov/Documents/contact-tracer-
assignment-information-for-state-departments.pdf.
Cal OES News. "A Comprehensive Look: Landmark COVID-19 Relief Program Great
Plates Delivered Wraps Up Operations." July 2, 2021. Accessed December 9, 2024.
https://news.caloes.ca.gov/a-comprehensive-look-landmark-covid-19-relief-program-
great-plates-delivered-wraps-up-operations/.
Cal OES News. “Cal OES has Distributed Over 1.6 Billion Pieces of PPE to Californians.”
January 31, 2022. Accessed December 9, 2024. https://news.caloes.ca.gov/cal-oes-
has-distributed-over-1-6-billion-pieces-of-ppe-to-californians/.
Cal OES News. “Governor Newsom Announces Emergency Allocation of $62 Million to
Local Governments to Protect People Living in Project Roomkey Hotels.” November
16, 2020. Accessed December 3, 2024, https://news.caloes.ca.gov/governor-newsom-
announces-emergency-allocation-of-62-million-to-local-governments-to-protect-
people-living-in-project-roomkey-hotels/.
151
COVID-19 After Action Report
Appendices
Cal OES News. “State Launches California COVID-19 Testing Sites Website.” May 6,
2020, Accessed December 9, 2024.https://news.caloes.ca.gov/state-launches-
california-covid-19-testing-sites-website/.
Cal OES News. “Unemployment benefits to pandemic-impacted workers reach $63.9
billing.” Augus 13, 2020. Accessed December 9, 2024.
https://news.caloes.ca.gov/unemployment-benefits-to-pandemic-impacted-workers-
reach-63-9-billion/.
Cal OES SOC. “Joint Incident Action Plan Operational Period 07-04-2020 to 07-05-
2020.” July 3, 2020.
Cal OES. “California Department of Aging, and CalHHS. Great Plates Delivered
Program Guidance." California Governor’s Office of Emergency Services.” Accessed
January 3, 2023.https://www.caloes.ca.gov/wp-
content/uploads/Recovery/Documents/037-great-plates-delivered-program-
guidance-AS-OF-05042020.pdf.
Cal OES. “California Distributes Millions of Additional PPE to Out-of-State Partners.”
June 29, 2020. Accessed December 9, 2024. https://news.caloes.ca.gov/california-
distributes-millions-of-additional-ppe-to-out-of-state-partners/
Cal OES. “California to Send Additional COVID-19 Supplies to South Asian Countries.”
June 2021.Accessed December 9, 2024. https://news.caloes.ca.gov/california-to-
send-additional-covid-19-supplies-to-south-asian-countries/
Cal OES. “Communication.” N.d. Accessed December 9, 2024.
https://www.caloes.ca.gov/office-of-the-director/policy-administration/access-
functional-needs/communication/
Cal OES. “COVID-19 AAR Questionnaire 2020 Grand Princess,” May 2020 (est).
Cal OES. “Federal and State Partners Protect the Community of Oakland while
Supporting the Safe Return of Passengers from the Grand Princess Cruise Ship.” March
9, 2020. Accessed December 9, 2024. https://news.caloes.ca.gov/federal-and-state-
partners-protect-the-community-of-oakland-while-supporting-the-safe-return-of-
passengers-from-the-grand-princess-cruise-ship/.
Cal OES. “Inclusive Planning Blueprint for Addressing Access and Functional Needs at
Mass Testing/Vaccination Sites.” November 2021. Accessed December 9, 2024.
https://www.caloes.ca.gov/wp-content/uploads/AFN/Documents/AFN-Library/Cal-
152
COVID-19 After Action Report
Appendices
OES-Inclusive-Planning-Blueprint-for-Addressing-AFN-at-Mass-Vaccination-and-Testing-
Sites.pdf.
Cal OES. “Interim 2020 COVID-19 Pandemic (January – August) After
Action/Corrective Action Report.” December 2020.
Cal OES. “Plans in Place to Assist Counties Statewide with Rising Number of COVID-19
Decedents (UPDATED).” January 11, 2021. Accessed December 9, 2024.
https://news.caloes.ca.gov/plans-in-place-to-assist-counties-statewide-with-rising-
number-of-covid-19-decedents-updated/.
Cal OES. “Project Roomkey: Impact to Date and Looking Ahead.” August 3, 2021.
Accessed December 3, 2024. https://news.caloes.ca.gov/project-roomkey-impact-to-
date-and-looking-ahead/.
Cal OES. “Type III EOC Position Credentialing Standards.” January 2022. Accessed on
December 9, 2024. https://www.caloes.ca.gov/wp-content/uploads/Type-III-Task-
Book-v3-revision1-2022.pdf.
CalHHS and Cal OES. “COVID-19 Situation Report, Report No. 494.” June 29, 2022.
CalHHS. “Newsom Administration Supplements Vaccine Delivery System; Announces
Creation of Statewide Vaccine Delivery Network to Simplify and Standardize
Vaccination Process with Equity as a Core Focus.” January 26, 2021. Accessed
December 9, 2024. https://www.chhs.ca.gov/blog/2021/01/26/newsom-
administration-supplements-vaccine-delivery-system-announces-creation-of-
statewide-vaccine-delivery-network-to-simplify-and-standardize-vaccination-process-
with-equity-as-a-core-focus/.
California Board of Registered Nursing.” Coronavirus Information Updates.” Accessed
December 9, 2024. https://www.rn.ca.gov/coronavirus.shtml.
California Department of Community Services and Development. “California Earned
Income Tax Credit.” Accessed December 9, 2024.
https://www.csd.ca.gov/Pages/CalEITC.aspx.
California Department of Finance. "State Fiscal Recovery Fund: California's Recovery
Plan." July 29, 2022. Accessed January 4, 2024. https://dof.ca.gov/wp-
content/uploads/sites/352/budget/covid-19/state-fiscal-recovery-fund/2022-
Recovery-Plan-FINAL-2022-07-29.pdf.
153
COVID-19 After Action Report
Appendices
California Department of Finance. “California Budget Summary 2021-22.” Accessed
December 9, 2024. https://ebudget.ca.gov/2021-
22/pdf/BudgetSummary/EconomicOutlook.pdf.
California Department of Finance. “Governor's Budget Summary 2021-22.” January
2021. Accessed December 9, 2024. https://ebudget.ca.gov/2021-
22/pdf/BudgetSummary/Introduction.pdf.
California Department of Food and Agriculture. “Housing for the Harvest – Program
Overview Document.” Accessed July 2023.
https://files.covid19.ca.gov/pdf/Housing_for_the_Harvest-Program_Overview.pdf.
California Department of Housing and Community Development. “Notice of Funding
Availability: Homekey Program.” July 16, 2020. Accessed December 9, 2024.
https://www.hcd.ca.gov/grants-funding/active-
funding/homekey/docs/2020_hcd_homekey-nofa_07-15-2020.pdf.
California Franchise Tax Board. “Golden State Stimulus.” Accessed December 9, 2024.
https://www.ftb.ca.gov/about-ftb/newsroom/golden-state-stimulus/index.html.
California Grants Portal. “California Small Business COVID-19 Relief Grant Program.”
May 26, 2023. Accessed December 9, 2024.
https://www.grants.ca.gov/grants/california-small-business-covid-19-relief-grant-
program/.
California Health and Safety Code § 101040
California School Boards Association. “COVID-19 closes nearly every California
school.” April 2020. Accessed December 9, 2024.
https://publications.csba.org/california-school-news/april-2020/covid-19-closes-nearly-
every-california-school/.
California State Assembly, Joint Committee on Economic Development and Emerging
Technologies. "JEDE Briefing Report: COVID-19 and Small Business." February 23, 2021.
Accessed January 4, 2024.
https://ajed.assembly.ca.gov/sites/ajed.assembly.ca.gov/files/5FINAL%20-
%20Feb%2023%20JEDE%20Briefing%20Report-COVID-
19%20and%20Small%20Business.pdf.
California Volunteers. “California volunteers deploys AmeriCorps VISTA members to
support long-term sustainable food bank strategy.” September 2, 2020. Accessed
154
COVID-19 After Action Report
Appendices
December 9, 2024. https://www.californiavolunteers.ca.gov/california-volunteers-
deploys-americorps-vista-members-to-support-long-term-sustainable-food-bank-
strategy/#:~:text=%E2%80%9CAt%20the%20start%20of%20the,Chief%20Service%20Offic
er%20Josh%20Fryday.
California Volunteers. “Operation Feed California.” Accessed December 9, 2024.
https://www.californiavolunteers.ca.gov/wp-
content/uploads/sites/116/2021/03/Operation-Feed-California-Fact-Sheet-1.pdf.
California Volunteers.” California volunteers deploys AmeriCorps VISTA members to
support long-term sustainable food bank strategy.” September 2, 2020. Accessed
December 9, 2024. https://www.californiavolunteers.ca.gov/california-volunteers-
deploys-americorps-vista-members-to-support-long-term-sustainable-food-bank-
strategy/#:~:text=%E2%80%9CAt%20the%20start%20of%20the,Chief%20Service%20Offic
er%20Josh%20Fryday.
CalPROTECT. “California State Prisons During the COVID-19 pandemic.” May 1, 2022.
Accessed December 9, 2024.
https://s3.amazonaws.com/cms.ipressroom.com/401/files/202308/2022-0501-
CalPROTECT-Report.pdf.
CDC. “COVID data tracker.” Accessed July 2023. https://covid.cdc.gov/covid-data-
tracker
CDC. “COVID Data Tracker.” February 16, 2023. Accessed December 9, 2024.
https://covid.cdc.gov/covid-data-tracker/#cases_totaldeaths.
CDC. “COVID Data Tracker.” February 16, 2023. Accessed December 9, 2024.
https://covid.cdc.gov/covid-data-tracker/#cases_totaldeaths.
CDC. “Public Health Responses to COVID-19 Outbreaks on Cruise Ships – Worldwide,
February-March 2020.” March 27, 2020. Accessed December 9, 2024.
https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e3.htm.
CDCR. “Actions to Reduce Population and Maximize Space.” Accessed December 9,
2024. https://www.cdcr.ca.gov/covid19/frequently-asked-questions-expedited-
releases/.
CDCR. “CDCR Week in Review: May 27, 2022.”
CDCR. “COVID-19 Response Efforts.” Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/covid-19-response-efforts/.
155
COVID-19 After Action Report
Appendices
CDCR. “COVID-19 Timeline.” Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/updates/.
CDCR. “Joint Incident Action Plan COVID-19 Operational Period 05.0 9.2020.”
CDCR. “Joint Incident Action Plan Operational Period 07.07.2020 to 07.08.2020.” July 6,
2020.
CDCR. “Joint Incident Action Plan Operational Period 07.08.2020 to 07.09.2020.” July 6,
2020.
CDCR. “Joint Incident Action Plan Operational Period 07.22.20 to 07.23.20.” July 21,
2020.
CDCR. “Joint Incident Action Plan Operational Period 07.28.20 to 07.29.20.” July
27,2020.
CDCR. “Update to visiting regulations.” February 2, 2023. Accessed December 9, 2024.
https://www.cdcr.ca.gov/covid19/update-to-visiting-regulations-2/.
CDCR.” Joint Incident Action Plan Operational Period 08.20.20 to 08.22.20.” August
19,2020.
CDE. “New School Emergency Reporting System” August 31, 2021. Accessed
December 9, 2024. https://www.cde.ca.gov/nr/el/le/yr21ltr0831.asp.
CDE. “State Superintendent Tony Thurmond Announces Major Collaboration with
Apple and T-Mobile to Connect Students in Need.” August 5, 2020. Accessed
December 9, 2024. https://www.cde.ca.gov/nr/ne/yr20/yr20rel65.asp.
CDPH. “CDPH Launches Let's Get to ImmUnity Campaign to Boost COVID-19 Vaccine
Acceptance.” March 17, 2021. Accessed December 9, 2024.
https://www.cdph.ca.gov/Programs/OPA/Pages/NR21-091.aspx.
CDPH. “COVID-19 AAR – Four Chapters.” October 2022.
CDPH. “COVID-19 AAR – Medical Surge.” October 2022.
CDPH. “COVID-19 AAR – Testing.” July 2024.
CDPH. “COVID-19 AAR – Vaccines.”
156
COVID-19 After Action Report
Appendices
CDPH. “COVID-19 AAR Chapter.”
CDPH. “COVID-19 AAR.” October 2022.
CDPH. “COVID-19 Multilingual Resources.” 2023.
CDPH. “COVID-19 Updates for February 23," February 23, 2023. Accessed December 5,
2024. https://www.cdph.ca.gov/Programs/OPA/Pages/NR23-012.aspx.
CDPH. “COVID-19 Vaccination Plan.” October 16, 2020. Accessed December 9, 2024
https://www.cdph.ca.gov/programs/cid/dcdc/cdph%20document%20library/covid-
19/covid-19-vaccination-plan-california-interim-draft_v1.0.pdf.
CDPH. “Resources for School-Located Vaccination Events.” Accessed December 9,
2024.
https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/School/resourc
es-clinics.aspx#.
CDPH.” COVID-19 AAR – Four Chapters”. October 2022.
CDPH. COVID-19 AAR – Medical Surge, October 2022 and EMSA. “COVID-19 AAR.”
CDPH. COVID-19 AAR and CalPROTECT Report
CDPH. COVID-19 AAR. October 2022.
DGS. “2020 Year in Review.” Accessed July 2023. https://www.dgs.ca.gov/-
/media/Divisions/DGS/Strategic-Plan/DGS-2020YearInReview-
ADA.pdf?la=en&hash=4B426C8785696CD16D540DA91D7D8B844BC92BE1.
EDD. “Pandemic Unemployment Assistance.” Accessed July 2023.
https://edd.ca.gov/en/about_edd/coronavirus-2019/pandemic-unemployment-
assistance.
EDD. “The EDD’s Response to Fraud.” Accessed December 9, 2024.
https://edd.ca.gov/en/about_edd/fraud-response/.
EMSA. “COVID-19 AAR.”
Executive Department, State of California. “Executive Oder N-44-20.” April 3, 2020.
https://www.gov.ca.gov/wp-content/uploads/2020/04/4.3.20-EO-N-44-20.pdf.
157
COVID-19 After Action Report
Appendices
Executive Department, State of California. “Executive Order N-41-20.” April 1, 2020.
Accessed July 2023. https://www.gov.ca.gov/wp-content/uploads/2020/04/4.1.20-EO-
N-41-20.pdf.
Executive Department, State of California. “Executive Order N-46-20.” April 7, 2020.
https://www.gov.ca.gov/wp-content/uploads/2020/04/4.7.20-EO-N-46-20.pdf.
Executive Department, State of California. “To Improve Statewide Vaccinations
Governor Newsom Announces Actions to Simplify, Standardize and Address Supply
Needs.” January 25, 2021.
Executive Order N-26-20
GAO. “Federal and State Coordination in the COVID-19 Vaccination Response, 2021.
GAO-22-104457.” November 04, 2021. Accessed December 9, 2024.
https://www.gao.gov/products/gao-22-104457.
GAO. Report 21-334
Housing and Social Services Task Force. COVID-19 AAR Questionnaire
HSD-STAC – CIP, ART, STRAT. COVID-19 AAR Questionnaire Responses
ICS 202 Task Force Priorities and Objectives.
LAO. “An Initial Look at Effects of the COVID-19 Pandemic on Local Government Fiscal
Condition.” May 2021. Accessed December 9, 2024.
https://lao.ca.gov/reports/2021/4428/COVID-19-Fiscal-Effects-Local-Gov-051221.pdf
LAO. “Assessing Proposals to Address Unemployment Insurance Fraud.” February 15,
2022. Accessed December 9, 2024. https://lao.ca.gov/Publications/Report/4542.
Listos California. “Listos California Impact Report.” May 2021.
https://www.listoscalifornia.org/wp-content/uploads/2021/06/Listos-California-Impact-
Report.pdf.
Live Edit Sessions
Logistics and Commodities Task Force. “After Action Review.” October 12, 2020.
OAFN. COVID-19 AAR Questionnaire, September 2020
158
COVID-19 After Action Report
Appendices
Office of the Governor. "Executive Order N-36-20." State of California” March 24, 2020.
Accessed December 9, 2024. https://www.gov.ca.gov/wp-
content/uploads/2020/03/3.24.20-EO-N-36-20.pdf.
Office of the Governor. "Executive Orders,"
https://www.gov.ca.gov/?s=executive+order.
Office of the Governor. “California Launches Interactive Map as Part of Safe Schools
for All Plan.” February 12, 2021.Accessed February 12, 2021.
https://www.gov.ca.gov/2021/02/12/california-launches-interactive-map-as-part-of-
safe-schools-for-all-plan/.
Office of the Governor. “California Public Health Experts: Mass Gatherings Should be
Postponed or Canceled Statewide to Slow the Spread of COVID-19.” March 11, 2020.
Accessed December 9, 2024. https://www.gov.ca.gov/2020/03/11/california-public-
health-experts-mass-gatherings-should-be-postponed-or-canceled-statewide-to-slow-
the-spread-of-covid-19/.
Office of the Governor. “California Sends India COVID-19 Supplies to Combat
Outbreak.” April 26, 2021. Accessed December 9, 2024.
https://www.gov.ca.gov/2021/04/26/california-sends-india-covid-19-supplies-to-
combat-outbreak/
Office of the Governor. “California's leading digital and media platforms, businesses,
and celebrities’ partner with the state to amplify covid-19 "stay home. save lives."
public awareness campaign.” 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/03/29/californias-leading-digital-and-media-platforms-
businesses-and-celebrities-partner-with-the-state-to-amplify-covid-19-stay-home-save-
lives-public-awareness-campaign.
Office of the Governor. “Governor Gavin Newsom Issues Stay at home Order.” March
19, 2020. Accessed July 2023. https://www.gov.ca.gov/2020/03/19/governor-gavin-
newsom-issues-stay at home-order/.
Office of the Governor. “Governor Newsom Announces Federal Health and Safety
Certification of Life-Saving N95 Maks.” June 8, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/06/08/governor-newsom-announces-federal-health-
and-safety-certification-of-life-saving-n95-masks/.
Office of the Governor. “Governor Newsom Announces New $2.7 Billion COVID-19
Emergency Response Package.” January 8, 2022. Accessed December 9, 2024.
159
COVID-19 After Action Report
Appendices
https://www.gov.ca.gov/2022/01/08/governor-newsom-announces-new-2-7-billion-
covid-19-emergency-response-package/.
Office of the Governor. “Governor Newsom Announces Plans to Lift Pandemic
Executive Orders as California Fully Reopens." June 11, 2021. Accessed December 9,
2024. https://www.gov.ca.gov/2021/06/11/as-california-fully-reopens-governor-
newsom-announces-plans-to-lift-pandemic-executive-orders/.
Office of the Governor. “Governor Newsom Issues Executive Order on State Prisons
and Juvenile Facilities in Response to the COVID-19 Outbreak.” March 24, 2020.
Accessed December 9, 2024. https://www.gov.ca.gov/2020/03/24/governor-newsom-
issues-executive-order-on-state-prisons-and-juvenile-facilities-in-response-to-the-covid-
19-outbreak/.
Office of the Governor. “Governor Newsom Issues Executive Order Protecting Homes,
Small Businesses from Water Shutoffs.” April 2, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/04/02/governor-newsom-issues-executive-order-
protecting-homes-small-businesses-from-water-shutoffs/.
Office of the Governor. “Governor Newsom Launches “Vaccinate all 58” Campaign
based on Safety and Equity as First Vaccines Arrive to California.” December 14, 2020.
Accessed December 9, 2024 https://www.gov.ca.gov/2020/12/14/governor-newsom-
launches-vaccinate-all-58-campaign-based-on-safety-and-equity-as-first-vaccines-
arrive-to-california/.
Office of the Governor. “Governor Newsom Launches One-Stop Website for Donations
& Sales of Essential Medical Supplies in Fight Against COVID-19.” April 4, 2020.
Accessed December 9,2024. https://www.gov.ca.gov/2020/04/04/governor-newsom-
launches-one-stop-website-for-donations-sales-of-essential-medical-supplies-in-fight-
against-covid-19/.
Office of the Governor. “Governor Newsom Marks End of California’s COVID-19 State
of Emergency.” February 28, 2023. Accessed December 9, 2024.
https://www.gov.ca.gov/2023/02/28/governor-newsom-marks-end-of-californias-
covid-19-state-of-emergency/
Office of the Governor. “Governor Newsom Outlines Steps to Protect Residents and
Employees of California Nursing Home & Residential Care Facilities.” Apr 10, 2020.
Accessed December 9, 2024. https://www.gov.ca.gov/2020/04/10/governor-newsom-
outlines-steps-to-protect-residents-and-employees-of-california-nursing-home-
residential-care-facilities/.
160
COVID-19 After Action Report
Appendices
Office of the Governor. “Governor Newsom Signs College Affordability and
Accessibility Legislation, Highlights $47.1 Billion Higher Education Package.” October
06, 202. Accessed December 9, 2024. https://www.gov.ca.gov/2021/10/06/governor-
newsom-signs-college-affordability-and-accessibility-legislation-highlights-47-1-billion-
higher-education-package/.
Office of the Governor. “Governor Newsom Signs Historic Housing and Homelessness
Funding Package as Part of $100 Billion California Comeback Plan.” July 19, 2021.
Accessed December 9, 2024. https://www.gov.ca.gov/2021/07/19/governor-newsom-
signs-historic-housing-and-homelessness-funding-package-as-part-of-100-billion-
california-comeback-plan/#:~:text=Plan%20%7C%20California%20Governor-
,Governor%20Newsom%20Signs%20Historic%20Housing%20and%20Homelessness%20Fu
nding%20Package%20as,%24100%20Billion%20California%20Comeback%20Plan&text=
Package%20includes%20%245.8%20billion%20to,with%20severe%20mental%20health%
20challenges.
Office of the Governor. “Governor Newsom Signs Statewide COVID-19 Tenant and
Landlord Protection Legislation.” August 31, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/08/31/governor-newsom-signs-statewide-covid-19-
tenant-and-landlord-protection-legislation/.
Office of the Governor. “Governor Newsom Unveils California’s Safe Schools for All
Plan.” December 30, 2020. Accessed December 9, 2024.
https://www.gov.ca.gov/2020/12/30/governor-newsom-unveils-californias-safe-
schools-for-all-plan/.
Office of the Governor. “Governor Newsome Marks End of California’s COVID-19 State
of Emergency.” February 28, 2023. Accessed December 9, 2024.
https://www.gov.ca.gov/2023/02/28/governor-newsom-marks-end-of-californias-
covid-19-state-of-emergency/.
OIG. "COVID-19 Review Series Part Three – Transfer of Patients from CIM." February
2021. Accessed December 9, 2024. https://www.oig.ca.gov/wp-
content/uploads/2021/02/OIG-COVID-19-Review-Series-Part-3-%E2%80%93-Transfer-of-
Patients-from-CIM.pdf.
OIG. “COVID-19 Review Series Part Two.” October 2020. Accessed December 9, 2024.
https://www.oig.ca.gov/wp-content/uploads/2020/10/OIG-COVID-19-Review-Series-
Part-2-%E2%80%93-Face-Coverings-and-PPE.pdf.
OLEA COVID-19 Narrative
161
COVID-19 After Action Report
Appendices
Regional Hotwash
RFI Responses
Stakeholder Hotwashes
Stakeholder Interviews
Stakeholder Questionnaire
State of California Green Buildings. “California Office of Emergency Services, Building
and Infrastructure Resilience.” N.d. Accessed December 9, 2024.
https://www.green.ca.gov/buildings/department/CAL%20OES.
State of California. “California for All, California’s Commitment to Health Equity.”
November 10, 2022. Accessed July 2023. https://covid19.ca.gov/equity/#community-
impact.
Survey Response
Task Force AAR
The Office of Private Sector / NGO Coordination.” COVID-19 After-Action Report
Questionnaire.” 2020.
UCG Action Items Tracker Spreadsheet
UCG Briefing Report. August 9, 2020.
UCG Briefing Report. March 1, 2020.
Table 5: Table of External References
External References
Alameda County Office of Homeless Care and Coordination. “Evaluating Project
Roomkey in Alameda County.” May 2021. Accessed December 9, 2024.
https://homelessness.acgov.org/homelessness-
assets/img/reports/Final%20PRK%20Report.pdf.
162
COVID-19 After Action Report
Appendices
Berkley Public Health. “COVID-19 Outbreak: San Quentin Prison.” June 15, 2020.
Accessed December 9, 2024. https://amend.us/wp-
content/uploads/2020/06/COVID19-Outbreak-SQ-Prison-6.15.2020.pdf.
Blue Shield of California. “Q&A: Blue Shield of California as the State of California's
third-party administrator.” March 19, 2021. Accessed December 9, 2024.
https://news.blueshieldca.com/2021/03/19/q-a-blue-shield-of-california-as-the-state-
of-californias-third-party-administrator.
Bohn, Sarah. “How Did California’s Economy Recover from COVID – What Comes
Next?” March 9, 2022. Accessed December 9, 2024. https://www.ppic.org/blog/how-
did-californias-economy-recover-from-covid-and-what-comes-next/.
Cucinotta D, Vanelli M. “WHO Declares COVID-19 a Pandemic. Acta Biomed.” March
2020 19;91(1):157-160. doi: 10.23750/abm.v91i1.9397.
Placer County. “Placer County announces death of patient with COVID-19.” March 4,
2020. Accessed December 9, 2024. https://www.placer.ca.gov/6438/Death-of-
patient-with-COVID-19.
SEIU Local 1000. “CDCR/CCHCS Continues to Ignore Legal Requirements With its
COVID N95 Mask Mandates.” January 11, 2022. Accessed December 9, 2024.
https://www.seiu1000.org/post/cdcrcchcs-continues-ignore-legal-requirements-its-
covid-n95-mask-mandates.
Steve Scauzillo. “Inland Officials Remember Flight from Coronavirus Epicenter in China
One Year Later.” January 28, 2021. Accessed on December 9, 2024.
https://www.pe.com/2021/01/28/inland-officials-remember-airlift-from-coronavirus-
epicenter-in-china-one-year-later/.
Tener Center for Affordable Housing and Community Development, University of
California, Berkeley. “California’s Homekey Program: Unlocking Housing Opportunities
for People Experiencing Homelessness.” March 2022. Accessed December 9, 2024.
https://ternercenter.berkeley.edu/wp-content/uploads/2022/03/Homekey-Lessons-
Learned-Final-March-2022.pdf.
Tener Center for Affordable Housing and Community Development, University of
California, Berkeley. “Homekey: Lessons Learned." March 2022.
https://ternercenter.berkeley.edu/wp-content/uploads/2022/03/Homekey-Lessons-
Learned-Final-March-2022.pdf.
163
COVID-19 After Action Report
Appendices
Travis Air Force Base. “HHS completes federal quarantine efforts for Grand Princess
passengers at Travis AFB.” April 1, 2020. Accessed December 9, 2024.
https://www.travis.af.mil/News/Article/2134053/hhs-completes-federal-quarantine-
efforts-for-grand-princess-passengers-at-travi/.
Travis Air Force Base. “Travis AFB continued support to HHS, Grand Princess
Repatriation.” March 10, 2020. Accessed December 9, 2024.
https://www.travis.af.mil/News/Article/2107527/travis-afb-continued-support-to-hhs-
grand-princess-repatriation/.
U.S. Food and Drug Administration. “Coronavirus (COVID-19) Update: FDA Issues
Emergency Use Authorization to Decontaminate Millions of N95 Respirators.” April 12,
2020. Accessed December 9, 2024. https://www.fda.gov/news-events/press-
announcements/coronavirus-covid-19-update-fda-issues-emergency-use-
authorization-decontaminate-millions-
n95#:~:text=The%20U.S.%20Food%20and%20Drug,care%20workers%20in%20hospital%2
0settings.
USDHHS, Office of Inspector General. “FDA repeatedly adapted emergency use
authorization policies to address the need for COVID-19 testing.” September 21, 2022.
Accessed on December 9, 2024. https://oig.hhs.gov/documents/evaluation/2617/OEI-
01-20-00380-Complete%20Report.pdf.
USDHHS, OIG. “The Strategic National Stockpile was not Positioned to Respond
Effectively to the COVID-19 Pandemic.” October 2023. Accessed December 9, 2024.
https://oig.hhs.gov/oas/reports/region4/42002028.pdf.
White, L.A., McCorvie, R., Crow, D. et al. “Assessing the accuracy of California county
level COVID-19 hospitalization forecasts to inform public policy decision making.” BMC
Public Health 23 (2023): 782. https://doi.org/10.1186/s12889-023-15649-0.
WHO. “Timeline of WHO’s Response to COVID-19.” January 29, 2021. Accessed
December 9, 2024. https://www.who.int/news-room/detail/29-06-2020-covidtimeline.
164
COVID-19 After Action Report
Appendices
APPENDIX C: EXECUTIVE ORDERS
ISSUED BY THE GOVERNOR’S OFFICE
The table below provides a brief description of the 76 executive orders issued by the
Governor’s Office during the COVID-19 response. The information is available on the
official California Governor's website. 367
Table 6: Executive Orders Issued by the Governor’s Office
Executive
Date Brief Description
Order
• Instructed Californians to follow public health
directives, including canceling large gatherings of
more than 250 people.
• Removed the waiting period for unemployment
and disability insurance for Californians who lost
work as a result of the COVID-19 outbreak.
N-25-20 March 12, 2020
• Allowed the state to commandeer hotels and
medical facilities to isolate and treat COVID-19
patients.
• Allowed local and state legislative bodies to hold
meetings via conference calls while still meeting
state transparency requirements.
• Mandated that school districts use dollars to fund
distance learning and high-quality educational
opportunities, safely provide school meals, and
arrange for the supervision of students during
school hours.
N-26-20 March 13, 2020
• Required the CDE and CalHHS to develop
strategies to address equity challenges around
internet connectivity, ensure students with
disabilities receive specialized education, and
safely provide meals.
• Updated state health guidance directing seniors
N-27-20 March 15, 2020 and COVID-19 vulnerable residents to isolate at
home.
367 Office of the Governor. "Executive Orders," https://www.gov.ca.gov/?s=executive+order.
165
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
• Redirected state agencies to protect licensed
facilities, staff, and residents most vulnerable to
COVID-19.
• Authorized local governments to halt evictions,
N-28-20 March 16, 2020 slows foreclosures, and added protection against
utility shut offs.
• Protected ongoing safety net services (Medi-Cal,
CalFresh, CalWORKs, the Cash Assistance Program
N-29-20 March 17, 2020 for Immigrants, the California Food Assistance
Program, or In Home Supportive Services) for most
vulnerable Californians.
N-30-20 March 17, 2020 • Suspended standardized testing for students.
• Waived the requirement to hold an active Motor
Carrier Property Permit pursuant to California
N-31-20 March 17, 2020 Vehicle Code section 34620 while conducting
intrastate transportation within California in support
of emergency relief efforts.
• Order to aid homeless Californians, among the
most vulnerable in the spread of COVID-19, safely
N-32-20 March 18, 2020 into shelter and housing.
• Granted local flexibility on spending and building
shelters.
• Stay at home order issued.
• Instructed the healthcare delivery system to
N-33-20 March 19, 2020 prioritize services to those who are the sickest and
prioritize resources for the providers providing direct
care to them.
• Protected public health by expanding vote-by-
N-34-20 March 20, 2020 mail options and extending deadlines for
Presidential Primary Canvass.
• Expanded the capacity to combat COVID-19 in
N-35-20 March 21, 2020
healthcare facilities.
• 30-day suspension of new commitments into state
prisons or juvenile facilities.
N-36-20 March 24, 2020
• Directed videoconferencing for all scheduled
parole suitability hearings starting April 2020.
• 30-day extension banning the enforcement of
N-37-20 March 27, 2020
eviction orders for renters affected by COVID-19.
166
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
• Enabled the California Chief Justice to take
N-38-20 March 27, 2020 emergency actions for the state’s courts to
conduct business during COVID-19.
• Expanded the healthcare workforce and staff, and
N-39-20 March 30, 2020 added additional hospital beds for the COVID-19
surge.
• 90-day extension for state and local taxes,
including sales tax for businesses impacted by
N-40-20 March 30, 2020 COVID-19.
• Extended licensing deadlines and requirements for
several industries.
• Deployed funds for hospital surge efforts, as well as
N-41-20 April 1, 2020
other needs related to the COVID-19 response.
• Protected consumers who may be unable to pay
N-42-20 April 2, 2020
for water service.
• Allowed healthcare providers to use video chats
and applications to provide health services without
N-43-20 April 3, 2020 the risk of penalty.
• Aligned with federal HHS guidelines and waivers
issued in response to COVID-19.
• Limited price increases from sellers on critical items,
N-44-20 April 3, 2020
such as food and medical supplies.
• Ensured guidance on prioritizing enrollment of
children of essential critical infrastructure workers
with state-subsidized childcare providers.
• Suspended restrictions on access to state-
N-45-20 April 4, 2020 subsidized childcare programs.
• Allowed the state to take advantage of new
federal flexibility to provide pandemic
Supplemental Nutrition Assistance Program benefits
to children to reduce food insecurity.
• Suspended certain revenue and taxation codes
N-46-20 April 7, 2020 and the California Code of Regulations for critical
materials that protect public health.
N-47-20 April 7, 2020 • Expanded support for vulnerable populations.
• Directed for youth serving time at the Division of
N-49-20 April 14, 2020 Juvenile Justice to be discharged safely and
expeditiously.
167
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
• Announced a new initiative to expand call center
hours at EDD to better assist Californians with
unemployment insurance applications.
• EDD also implemented a one-stop shop for those
N-50-20 April 15, 2020 applying for PUA, including the self-employed and
independent contractors.
• Announced $75 million in statewide Disaster Relief
Assistance funding to provide financial support for
immigrant workers affected by COVID-19.
• Benefited workers in grocery stores and fast-food
chains, and delivery drivers.
N-51-20 April 16, 2020 • Gave two weeks of supplemental paid sick leave
to certain food sector workers subject to a
quarantine or isolation order or medical directive.
• Addressed admissions criteria for the CSU system,
N-52-20 April 16, 2020 background checks for essential workers, and
deadline extensions to real estate licenses.
• Issued temporary waivers to specific foster youth
N-53-20 April 17, 2020
programs to ensure continuity of care.
• Provided a 60-day extension for customers on
several Department of Motor Vehicles deadlines.
• Allowed certain posting, filing, and notice
N-54-20 April 22, 2020 requirements under the California Environmental
Quality Act to be satisfied through electronic
means to allow public access and involvement
consistent with COVID-19 public health concerns.
• Temporarily allowed retailers, particularly grocery
stores, to provide bags to consumers without
N-54-20 April 22, 2020 charge and to pause the redemption of beverage
containers in-store to mitigate the spread of
COVID-19.
• Provided flexibility to Department of Healthcare
Services and Medi-Cal providers on a variety of
N-55-20 April 22, 2020 deadlines and requirements to ensure continuity of
service to patients and customers is not impacted
by the effects of the COVID-19 pandemic.
168
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
• Extended the deadlines for completing annual
N-56-20 April 22, 2020 planning processes to enable LEAs to prioritize
more exigent needs.
• Exempts garnishment for any individuals receiving
federal, state, or local government financial
N-57-20 April 23, 2020
assistance in response to the COVID-19 pandemic,
including payments under the CARES Act.
• Allowed adults to obtain marriage licenses via
N-58-20 April 30, 2020 videoconferencing rather than in-person amidst
the COVID-19 pandemic.
• Temporarily broadened the capability of counties
to enroll persons into the CalWORKs program using
N-59-20 May 1, 2020
various eligibility verification methods due to social
distancing requirements.
• Directed the State Public Health Officer to establish
criteria to determine whether and how local health
N-60-20 May 4, 2020 officers may implement public health measures less
restrictive than the statewide public health
directives.
• Waived penalties on property taxes for residents
and small businesses experiencing economic
N-61-20 May 6, 2020 hardship based on COVID-19.
• Extended the deadline for filing property tax
statements.
• Created a time-limited rebuttable presumption for
accessing worker’ compensation benefits
N-62-20 May 6, 2020
applicable to Californians who must work outside
of their homes during the stay at home order.
• Extended some critical deadlines for certification
requirements for public school project inspectors
that have been impacted by the COVID-19
pandemic.
N-63-20 May 7, 2020 • Enhanced public safety by allowing retired peace
officers to temporarily be reemployed for up to a
year if they left the agency in good standing.
• Provided a 60-day extension on expiration dates
for notaries public whose commissions are set to
169
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
expire and procedural deadlines of the
Department of Industrial Relations.
• Protected Public Health by mailing every registered
N-64-20 May 8, 2020 voter a ballot ahead of the November General
Election.
• Waived the deadline to verify grade point
average, certain certification requirements, and
selective service registration verification for Cal
Grant applicants.
• Suspended programmatic deadlines for entities
that receive funding from the Energy Commission
N-65-20 May 19, 2020
for the development and deployment of new
technologies that support the state’s clean energy
and decarbonization goals.
• Extended the timeframe for local governments to
submit claims for reimbursement to the State
Controller’s Office.
• Issued a 30-day extension for local governments to
N-66-20 May 29, 2020 halt evictions for renters impacted by the COVID-
19 pandemic.
• Allowed individuals enrolled in teacher preparation
programs during the 2019-20 school year to obtain
their preliminary credential without a teaching
N-66-20 May 29, 2020
performance assessment if the individual was
unable to complete that requirement due to a
COVID-19 school closure.
• Ensured that Californians could exercise their right
N-67-20 June 3, 2020 to vote in a safe, secure, and accessible manner
during the November 2020 election.
• Helped increase the availability of hand sanitizer
N-68-20 June 5, 2020
and medical devices.
• Extended waivers, temporarily broadening the
capability of counties to enroll persons into the
CalWORKs program, allowing for self-attestation of
N-69-20 June 15, 2020 pregnancy and eligibility conditions, and waiving
in-person identification requirements.
• Extended permission for commercially licensed
food trucks to operate in roadside rest areas, in
170
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
compliance with a temporary permit issued by
Caltrans to ensure essential infrastructure workers
have access to food; suspended face-to-face visits
for eligibility for extended foster care; and
extended deadlines related to the payment of real
estate license application and renewal fees and
continuing education requirements for licensees.
• Extended a waiver that allows retailers to
temporarily pause in-store redemption of beverage
containers to mitigate the spread of COVID-19.
N-70-20 June 22, 2020
• Temporarily suspended the requirement for
recycling centers to hold a minimum number of
hours of operation.
• Issued a 30-day extension for local governments to
N-71-20 June 30, 2020 halt evictions for renters impacted by the COVID-
19 pandemic.
• Extended waivers, temporarily broadening the
capability of counties to enroll persons into the
CalWORKs program, allowing for self-attestation of
pregnancy and conditions of eligibility, and
waiving in-person identification requirements.
• Extended provisions allowing for mail-in renewals of
N-71-20 June 30, 2020
driver’s licenses and identification cards, limited in-
person transactions at the Department of Motor
Vehicles, and extended timeframes related to the
payment of real estate license application and
renewal fees and continuing education
requirements for licensees.
• Extended the deadline for county assessment
N-72-20 July 31, 2020 appeals boards to issue a decision on pending tax
assessment appeals filed.
• Directed state agencies across the government to
N-73-20 August 14, 2020
help bridge the digital divide.
• Helped increase the availability of CLIA-waived
COVID-19 testing and addressed a variety of issues
N-75-20 August 24, 2020 in response to the pandemic.
• Increased the income-eligibility threshold for the
Community Service Block Grant program to
171
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
support economic and community development
efforts in response to the pandemic, and waived
certain requirements under state law so that
additional Low Income Home Energy Assistance
Program funding made available under the CARES
Act could be used to maximize direct assistance to
Californians most in need.
• Waived time limits to allow individuals to continue
receiving CalWORKs benefits; permitted the
Franchise Tax Board to share tax return information
with the Department of Social Services to inform
individuals of CARES Act available to them; and
increased the health care capacity of home
health agencies and pediatric day health and
respite care facilities.
• Assisted elections officials as they prepared for the
N-76-20 August 26, 2020 November 2020 election amid the COVID-19
pandemic and wildfires across the state.
• Helped increase state testing capacity by
N-77-20 August 28, 2020
operating three sites for use as laboratories.
• Extended consumer protections against price
N-78-20 September 3, 2020 gouging for 30-days as California continued to
respond to the COVID-19 pandemic.
• Issued a 30-day extension for local governments to
September 23,
N-80-20 halt evictions for renters impacted by the COVID-
2020
19 pandemic.
• Directed Caltrans to create a process for issuing
temporary encroachment permits enabling
commercial activities on the State highway right-
of-way, allowing businesses located along state
highways to expand their outdoor dining options
onto sidewalks and parking areas where safety
N-83-20 October 28, 2020
permits.
• Allowed people 70 years or older to renew their
driver’s licenses by mail, further limiting in-person
transactions at the Department of Motor Vehicles
and helping this vulnerable COVID-19 population
isolate at home.
172
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
• Extended provisions related to deadlines for the
payment of real estate license application and
renewal fees and continuing education
requirements for licensees.
• Extended provisions related to deadlines for the
payment of real estate license application and
renewal fees and continuing education
requirements for licensees.
• Extended the availability of housing for migrant
agricultural workers, providing a 90-day extension
N-84-20 December 14, 2020 on tax returns and tax payments for small
businesses and updating Cal/OSHA requirements
related to quarantine guidelines.
• Allowed migrant farm labor centers managed by
the Department of Housing and Community
Development to continue housing agricultural
workers and their families beyond the statutory
occupancy period.
• Allowed the California Department of Tax and Fee
N-84-20 December 14, 2020
Administration to offer a 90-day extension for tax
returns and tax payments for all businesses filing a
return for less than $1 million in taxes.
• Updated Cal/OSHA Emergency Temporary
Standard in keeping with new guidance from the
CDPH related to quarantine guidelines.
• Extended the validity of medical cannabis
N-01-21 January 21, 2021 identification cards that would otherwise have
expired.
• Confirmed that existing law, which protects certain
healthcare professionals and providers from legal
liability when they render services at the request of
state or local officials during a state of emergency,
protected those healthcare professionals and
N-02-21 January 27, 2021
providers when they participated in the state’s
vaccine administration program.
• Clarified Physicians, pharmacists, dentists, nursing
professionals, and individuals like pharmacy
technicians, under the supervision or guidance of
173
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
these healthcare providers, participating in the
state's vaccine program are covered by liability
protections, given they comply with federal
authorization for administered vaccines and follow
state directives.
• Clarified Physicians, pharmacists, dentists,
registered nurses, nurse practitioners, other nursing
professionals, and individuals like pharmacy
technicians, under the supervision or guidance of
these healthcare providers.
• participating in the State's vaccine program are
covered by liability protections, given they comply
with federal authorization for administered
vaccines and follow state directives.
• Directed the Department of Consumer Affairs’
disciplinary bodies to prioritize disciplinary
N-02-21 January 27, 2021
proceedings and investigations against licensees
alleged to have diverted vaccine supplies for
financial gain, providing reassurance to
vaccinators that they are protected from
professional discipline when otherwise performing
their duties.
• Issued a 60-day extension for local governments to
N-03-21 March 4, 2021 halt evictions for renters impacted by the COVID-
19 pandemic.
• Terminated the Stay at Home Order and rolled
N-08-21 June 11, 2021
back additional pandemic order provisions.
• Expedited Cal/OSHA’s revised COVID-19
N-09-21 June 17, 2021 regulations to ensure consistency with public
health guidance.
• Extended provisions implemented to expand
California’s healthcare workforce during the
pandemic, including allowing healthcare workers
N-12-21 August 16, 2021 from out of state to provide services in California
and enabling certain medical personnel and
emergency medical technicians to continue
supporting the state’s COVID-19 response.
174
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
• Allowed healthcare facilities the flexibility to plan
and adapt their space to accommodate patients.
N-12-21 August 16, 2021 • Provided more flexibility for retired teachers and
school staff to return to fill short-term staffing
shortages.
• Waived the application of AB 361 10-days when
the provisions of a prior executive order that
September 20,
N-15-21 established certain requirements for public
2021
agencies to meet remotely during the COVID-19
emergency expired.
• Extended the provisions of a prior order that
facilitated telehealth services by enabling medical
September 27,
N-16-21 providers to conduct routine and non-emergency
2021
medical appointments through telehealth without
the risk of being penalized.
• Extended flexibilities which allowed the state to
increase healthcare capacity to support ongoing
N-17-21 October 4, 2021 testing and vaccination efforts and minimize the
threat of COVID-19 to Californians and healthcare
workers.
• Directed state agencies to continue coordinating
with the Biden-Harris Administration Supply Chain
Disruptions Task Force to address state, national,
and global supply chain challenges.
• Directed the Department of Finance to work with
state agencies to develop longer-term solutions to
N-19-21 October 20, 2021
support port operations and goods movement for
consideration in the January 10 governor’s Budget,
possible port and transportation infrastructure
improvements, electrification of the goods
movement system from port to delivery, and
workforce development.
• Directed state agencies to identify state-owned
properties and other locations that could be
available to address short-term storage needs
N-19-21 October 20, 2021
once goods are unloaded from ships, identified
priority freight routes to be considered for a
temporary exemption to current gross vehicle limits
175
COVID-19 After Action Report
Appendices
Executive
Date Brief Description
Order
to allow for trucks to carry additional goods, and to
create workforce training and education
programs.
• Ensured the state’s healthcare facilities continued
to have the staffing and resources needed to
prevent potential strain on the state’s healthcare
N-21-21 November 10, 2021
delivery system as the state prepared for a
potential new surge in COVID-19 cases over the
winter.
• Temporarily allowed corporate shareholder
N-23-21 December 16, 2021
meetings to be held virtually during emergencies.
• Extended the sunset of AB 361, which the governor
signed in September 2021, to extend the flexibilities
provided in a prior executive order enabling public
N-01-22 January 5, 2022 agencies to meet remotely during the COVID-19
emergency.
• Extended state bodies to continue holding public
meetings via teleconference for 90-days.
• Established consumer protections against price
N-02-22 January 8, 2022
gouging on at-home test kits.
• Provided flexibility for schools to deploy qualified
N-03-22 January 11, 2022 staff to address short-term staffing shortages and
support safe, in-person instruction.
• Rolled back additional COVID-19 related executive
N-04-22 February 25, 2022
actions.
• Updated Cal/OSHA COVID-19 Emergency
N-05-22 February 28, 2022 Temporary Standard, keeping with the current
guidance.
• Established consumer protections against price
N-10-22 June 7, 2022
gouging on infant formula.
• Lifted additional COVID-19 related executive order
provisions while maintaining key components of
N-11-22 June 17, 2022
the state’s SMARTER Plan to guide California’s
response to the pandemic.
176
COVID-19 After Action Report
Corrective Action Plan
APPENDIX D: CORRECTIVE ACTION PLAN
This Corrective Action Plan (CAP) details findings and their recommended corrective action for Cal OES COVID-19 After
Action Report. Cal OES continues to learn from the unprecedented impacts of COVID-19. Prioritizing these improvement
recommendations requires careful consideration of implementation time frames, resource availability, and support.
While Cal OES may not fully achieve every corrective action listed, programmatic goals and resource changes over
time may influence adjustments or revisions.
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
1.1.1 Unified Integrating Medical and Establish and operationalize the Medical and Cal OES and CDPH
Response Health Coordination Health Coordination Center in collaboration with
Center staff into the Emergency Support Function-8 stakeholders and
State Operations Center provide targeted training for large-scale incidents
required extensive requiring public health emergency support.
collaboration and • Develop and implement training modules
training, which posed a for MHCC staff on SEMS, ICS, and SOC
significant learning operations.
curve. • Conduct cross-training sessions for public
health and emergency management
teams to enhance mutual understanding
of protocols and response plans.
• Define operational roles, create public
health-focused organizational charts, and
develop tailored Incident Action Plans for
medical and health responses.
177
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Conduct large-scale public health
exercises to strengthen MHCC-SOC
integration and foster collaboration with
ESF-8 stakeholders.
1.1.1 Unified Responding to the Codify lessons learned from the COVID-19 Cal OES
Response pandemic required pandemic into emergency planning,
state-level decision- Standardized Emergency Management System
making that balanced doctrine, and training to prepare for future
local considerations statewide responses.
and coordinated with • Engage local governments and
community community partners in planning statewide
stakeholders. responses to better incorporate local
perspectives and manage expectations for
communication and operations.
• Update SEMS doctrine and training to
highlight its adaptability and codify COVID-
19 lessons learned for future statewide
responses.
1.1.2 Task The introduction of task Standardize Task Force roles within the Incident Cal OES
Forces forces caused confusion Command System structure of the State
and communication Operations Center.
problems within the • Develop job action sheets for task force
Incident Command positions aligning with ICS terminology,
System structure, guidelines, and organizational charts.
disrupting roles, • Provide training modules for pre-
information sharing, and established task force representatives,
178
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
situational awareness. SOC, and UCG staff to support task force
integration within the ICS and SEMS
framework.
• Establish clear reporting procedures for task
forces through the Operations Section
within the SOC.
• Activate task forces during regular
exercises.
1.1.2 Task The limited number of Expand Task Force Coordinators' resources to Cal OES
Forces coordinators for the 19 establish an appropriate span of control.
task forces hindered • Assess the workload and responsibilities of
information flow, each task force to allocate the
resulting in overlapping appropriate number of coordinators and
responsibilities. manage the span of control.
• Develop job action sheets for task force
coordinators aligning with ICS terminology,
guidelines, and organizational charts.
• Adopt a plan or procedure to include
collaboration mechanisms, such as regular
meetings and information-sharing
platforms, between task force coordination
and relevant state responders, including
OAFN.
• Exercise information sharing and
coordination plans and procedures for
operationalizing future response efforts.
179
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
1.2.2 Initial The Emergency Revise and expand the State Repatriation Plan to CDSS and Cal OES
Response Repatriation Plan did include public health emergency considerations
Coordination not address public and lessons learned from COVID-19.
health emergency • Develop guidance for isolating and
considerations. quarantining exposed populations while
ensuring access to medical care.
• Plan contingencies for quarantine site
changes, including staff reallocation and
logistics protocols.
• Conduct regular pandemic-focused
exercises with the Administration for
Children and Families and other key
agencies to validate the updated
repatriation plan.
• Enhance training program modules for
state personnel involved in repatriation
efforts, integrating pandemic-specific
modules.
1.2.2 Initial Challenges arose in Exercise the revised State Emergency CDSS and Cal OES
Response repatriating citizens due Repatriation Plan in collaboration with local,
Coordination to complexities in state, and federal partners, incorporating
navigating federal and scenarios related to public health emergencies.
international partners, • Include foreign consulates, federal
processes, and agencies, and local partners in repatriation
guidance. exercises.
180
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Review international regulations and
processes to identify barriers from past
responses and mitigate future challenges.
1.2.3 Operational Area Develop a plan or procedure for coordination Cal OES
Coordination Coordination Group group calls involving Operational Areas during
Calls calls with the State emergencies.
Operations Center often • Expand speaker representation from state
lacked participation agencies to provide comprehensive and
from appropriate state timely updates during coordination calls.
agency personnel and • Facilitate interactive sessions during calls,
did not always allow allowing for question-and-answer sessions
additional Operational or open forums to encourage stakeholder
Area personnel to engagement.
attend. • Implement a structured communication
plan for timely information dissemination
between coordination calls using
newsletters, email, or online portals.
• Establish mechanisms to encourage input
and feedback from local and regional
government representatives.
• Invite regional Cal OES Emergency Services
Coordinators to attend coordination calls.
181
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
1.2.4 State State staff often Unify workplace safety guidance across state Cal/OSHA and CDPH
Employee received contradictory agencies.
Coordination workplace safety • Establish a centralized task force or
guidance from workgroup involving Cal/OSHA, CDPH, and
agencies. other stakeholders to create consistent
workplace safety guidance.
• Align state guidance with federal updates,
including FDA and CDC standards, to
prevent contradictions.
• Implement centralized approval and
dissemination mechanisms through the JIC
to ensure clear communication for both
internal and external audiences.
1.2.4 State The absence of formal Develop comprehensive training and a Cal OES
Employee Incident Command structured onboarding process for all personnel
Coordination System training for involved in emergency response roles.
inexperienced staff • Establish a statewide policy requiring all
hindered operational new hires involved in emergency response
flow at the State roles, including E-hires, to complete certain
Operations Center level. SEMS and IS (100, 200, 700, and 800)
courses.
• Implement standardized Just-In-Time
Training (JITT) for SOC roles, with clear
communication and reporting protocols.
182
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Enhance screening and hiring processes to
align candidates’ skills with response
needs.
• Integrate limited-term staff early on in
response to facilitate proper training and
support for temporary staff.
1.2.4 State Staff attrition in state Implement measures that support employee well- CalHR and SPB
Employee agencies was driven by being and streamline Human Resources
Coordination long workdays, response emergency hiring processes.
conditions, and high • Reform and expedite hiring procedures to
retirement rates leading reduce vacancy rates in critical agencies,
to an understaffed aiming for faster recruitment and
workforce. onboarding timelines.
• Expand mental health support programs
for state responders, offering access to
counseling and stress management
resources.
• Introduce flexible work policies to
accommodate staff needs, promoting
work-life balance and reducing stress
levels.
• Implement structured staff rotation
schedules and mandatory rest periods to
prevent burnout and fatigue.
183
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Establish succession planning to retain
institutional knowledge amid high
retirement rates.
2.1.1 Data The state faced Invest in upgrading data system capabilities to CDPH and EMSA
Modeling challenges with its data handle high volumes and complex health data.
and systems related to • Upgrade legacy systems to scalable,
Forecasting developing and cloud-based platforms capable of
updating public health integrating diverse data sources.
guidance. • Implement data validation protocols to
improve the accuracy of new data
systems.
• Provide training to state health officials and
data analysts to ensure the workforce is
equipped to handle new systems and
make informed decisions based on the
latest data.
2.1.3 Contradictory guidance Coordinate with state agencies to produce CalHHS
Guidance from state agencies led consistent guidance, ensuring uniformity in
to confusion and messaging and requirements.
challenges in areas like • Form a working group which includes
workplace protections, members of all state agencies involved in
assisted living facilities, the response and is tasked with developing
medical support, and and producing guidance reflecting a
alignment between single unified voice. Ensure this working
state and federal group can quickly and efficiently adapt
184
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
guidelines. guidance to reflect changing federal
guidance or information.
• Assign a single entity, like the JIC, to review
and finalize all agency guidance
documents related to response operations
and improve consistency in messaging and
requirements.
2.1.4 A centralized approach Develop a procedure to gather real-time CDPH and Cal OES
Centralized created challenges in feedback from local jurisdictions on the
Approach implementing one-size- implementation of statewide policies.
fits-all guidance at the • Hold regular debriefings with local
local level. jurisdictions to collect reports on policy
successes and areas for improvement to
inform response efforts.
• Improve transparency in decision-making
processes by providing detailed insights
into the factors influencing decisions,
including data-driven and scientific
considerations.
2.2.1 Access Californians with Develop and implement strategies to ensure CDPH
and disabilities raised vaccine distribution plans account for disability
Functional concerns about the access and equity beyond age-based eligibility
Needs state's vaccine criteria.
distribution plan. • Conduct a risk assessment of factors that
lead to higher rates of infection, serious
symptoms, or other differential impacts and
185
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
incorporate into future medical
countermeasure prioritizations.
• Identify strategies for strengthening
healthcare access and trust with people
who are medically underserved.
• Engage community partners directly in
future pandemic planning, including
people who are medically underserved,
racial and ethnic minority groups, and
those at higher risk of infection and serious
symptoms.
• Outline tiered/score-based process to
enhance the equitable distribution of
vaccines and pharmaceuticals to the
public.
3.1.1 Joint The delayed Set a clear threshold for Joint Information Center Cal OES
Information mobilization of the Joint activation during an emergency response.
Center Information Center at • Determine EOC activation levels that
the pandemic’s onset trigger JIC mobilization under the State
resulted in redundant Emergency Plan.
messaging. • Develop a protocol for scaling JIC
operations according to the incident size
and scope, including the need for a virtual
JIC and contingency staffing.
186
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Develop unified protocols for state
agencies, including Cal OES and CDPH, to
streamline public messaging.
• Standardize agency information
dissemination through centralized
communication platforms.
3.1.2 The state's decision to Create an information prioritization system and Cal OES
Information prioritize notification protocol to enhance communication
Sharing communication policy with local officials and response partners.
and guidance without • Prioritize the release of critical life safety
lead time to local information while scheduling less urgent
officials left them updates to provide response partners with
unprepared to address preparation time. Develop and distribute
public questions. concise fact sheets summarizing key points
or policy changes.
• Coordinate with state agencies to align
regular call schedules, avoiding overlaps
and enhancing participation. Utilize JIC
resources to maintain and share a unified
call schedule.
• Establish dedicated feedback channels for
partners to share insights on recently
released and upcoming guidance,
fostering a collaborative response
framework.
187
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
3.2.3 The state faced Expand targeted communication strategies using Cal OES
Equitable challenges in reaching diverse media platforms, community networks,
Public target audiences with and culturally appropriate outreach to improve
Messaging key messages during message delivery and audience engagement.
the response. • Engage trusted community organizations
during both planning and response to
inform and amplify public messaging to
historically underserved communities.
• Increase engagement with community
organizations to disseminate information to
those lacking access to traditional
communication forms like television, radio,
and the internet.
• Issue messages in accessible,
understandable formats, such as holding a
press conference and launching a video
campaign with engaging visuals and
simple language to explain new
requirements.
4.1.1 Testing The rapid increase in Strengthen the state’s public health lab CDPH
Task Force demand challenged infrastructure and establish resilient supply chain
the state's ability to protocols to enhance testing response
effectively adapt and capabilities.
operationalize testing • Develop public/private partnerships with
resources. commercial labs to quickly accommodate
high-volume testing, to support public
188
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
health labs maintain their reference
capability.
• Develop a strategic reserve of critical
supplies (pipettes, reagents, plastics) to
reduce reliance on external suppliers
during surges.
• Establish a prioritized supply chain protocol
to quickly allocate resources to the most
impacted labs, improving turnaround
times.
• Explore capability building options or
funding to expand lab capacity and
ensure readiness for future public health
needs.
4.1.1 Testing Relying on contractors Develop a clear contract that defines CDPH
Task Force without public health qualifications, roles, and responsibilities of the
expertise hindered the contractors. Include structured onboarding and
Testing Task Force’s integration protocols to ensure their expertise
operational aligns with their roles.
effectiveness and policy • Create guidelines and communication
clarity. channels to integrate contractors into
policy discussions while avoiding
misalignment with state staff.
• Prioritize recruiting contractors with
expertise in public health, laboratory
science, or clinical testing to improve
189
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
contributions to policy discussions and
operational decisions.
• Screen candidates for technical
backgrounds that align with high-demand
testing roles to match qualifications with
operational needs.
• Create onboarding guidelines and
communication channels to define
contractor roles in policy, decision-making,
and technical support.
• Develop job action sheets within the ICS
framework to define contractor roles
during onboarding.
4.2.1 California Connected Develop an infrastructure plan for implementing CDPH
California program encountered programs similar to California Connected.
Connected administrative • Conduct a comprehensive assessment
Program challenges during its and gap analysis of the infrastructure
development and needed for the California Connected
operation. program, detailing anticipated needs for
supervisors, case investigators, technical
specialists, and support staff, with a focus
on scalability.
• Develop a staffing plan to anticipate
needs and align with program goals.
• Establish clear guidelines on potential
redirections by including criteria for
190
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
selecting employees and the process for
transitioning them into new roles.
• Identify staffing leads responsible for
overseeing the deployment of staffing
strategies and addressing related
challenges.
4.3.2 Medical Alternate Care Sites Develop state models for expanding current CDPH and EMSA
Surge were underutilized due space in medical facilities to accommodate
Capacity to evolving pandemic potential surges in patient care demand.
needs, guidelines, and • Work with local partners to identify
resources. strategies and resources needed to
successfully expand existing space for
patient care.
• Identify best practices and develop
guidance to expand space in medical
facilities. Incorporate guidance on patient
intake methods, public access
requirements, and AFN accommodations.
• Work with local jurisdictions to identify all
pre-determined locations and support
jurisdictions in identifying alternate
locations.
• Conduct functional exercises with local
jurisdictions to simulate expansion and
management of additional resources.
191
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Set up statewide contracts for medical
and wraparound service support for use
during future disaster responses.
• Create a structured feedback mechanism
to systematically collect local jurisdiction
and stakeholders' feedback on receiving
and utilizing the FMS cache.
• Conduct an assessment of “field hospitals
in a box” resources used during the
pandemic. This assessment should aim to
develop a comprehensive list of necessary
supplies required to support additional
patients.
4.3.3 Medical The healthcare demand Establish partnerships with educational institutions CDPH and EMSA
Professional swiftly depleted the pre- and healthcare organizations to create targeted
Shortage pandemic workforce and accelerated healthcare training programs.
and volunteer capacity. • Recruit individuals from diverse
backgrounds or career paths to transition
or upskill into healthcare roles.
• Support training initiatives in high-demand
healthcare fields such as nursing.
4.3.3 Medical Staffing contracts with Negotiate and regulate fair pricing for health CDPH and EMSA
Professional inflated costs created and medical surge staff and resources for
Shortage barriers for statewide emergencies during steady state.
supplemental • Implement a system for healthcare facilities
healthcare and to report cases of inflated costs or unfair
192
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
medical support. pricing practices by staffing agencies,
allowing for timely intervention and
enforcement of regulations.
• Collaborate with industry stakeholders to
establish fair and transparent pricing
practices for emergency staffing.
4.3.3 Medical Contracted healthcare Strengthen oversight of state-contracted CDPH and EMSA
Professional personnel were often healthcare personnel by improving training
Shortage undertrained and programs and distribution protocols for protective
lacked an adequate equipment.
supply of personal • Develop and implement a standardized,
protective equipment. training program for state-contracted
healthcare personnel prior to deployment.
Include requirements for fit-testing and
proper use of PPE to promote safe working
conditions.
• Establish a certification or vetting process
for staffing agencies contracted by the
state to maintain compliance with training,
equipment, and quality standards.
• Require state agencies to provide
contracted personnel with adequate PPE
supplies and enforce adherence to safety
protocols.
193
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
4.4.1 Federal Communication delays Conduct regular full-scale exercises with federal CDPH
Vaccine and breakdowns and local partners to simulate federal/state
Rollout between the state and vaccine distribution and administration.
the federal government • Include objectives focused on enhancing
hindered effective communication and information sharing to
planning for the mass strengthen intergovernmental planning.
vaccination sites. • Work with federal and local stakeholders to
develop effective plans for mass
vaccination sites, including clear state
guidelines.
4.4.3 The state struggled to Evaluate myCAvax’s performance to prepare for CDPH and EMSA
MyCAvax simultaneously roll out future challenges posed by pandemics and
PrepMod/COVIDReadi infectious disease responses.
and rapidly develop its • Conduct a thorough assessment of the
replacement, existing vaccine management system to
myCAvax. ensure it is scalable and flexible,
accommodating challenges in vaccine
supply, distribution, and administration
protocols.
• Involve local health jurisdictions and other
key stakeholders in the training and
implementation of the system.
• Prioritize interoperability with relevant state
and federal partners and systems such as
electronic health records to streamline
data sharing and reporting.
194
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Ensure the system can support different
vaccine distribution scenarios to prepare
for future infectious disease responses.
4.4.4 My Turn The My Turn platform Enhance the functionality and accessibility of the CDPH
encountered several My Turn Platform.
challenges during its • Revamp the My Turn interface to facilitate
initial rollout. smoother navigation and user-friendly
scheduling of vaccine appointments.
Ensure the platform's compatibility with
multiple devices, languages, and
accessibility features to cater to diverse
user needs.
• Implement system upgrades to ensure
accurate and real-time logging of all
administered vaccine doses. Address
glitches that cause underreporting of
vaccination data by enhancing the
system's capacity to capture and record
all vaccination activities.
• Develop a flexible system to swiftly adapt
to changing eligibility criteria.
• Expand My Turn to include a wider range
of vaccination sites and increase slot
availability.
195
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Create training on the use of My Turn and
conduct this training with state, local, and
private response partners regularly.
• Exercise the use of My Turn with state, local,
and private response partners regularly to
identify and mitigate technical and human
error issues impacting system access and
function.
4.4.5 Third The state announced Update the statewide mass vaccine distribution CDPH
Party the third-party plan that incorporates lessons learned from the
Administrator administrator after pandemic and addresses local needs.
many local entities had • Collaborate with local response partners to
already developed identify best practices and lessons learned
vaccine provider from the COVID-19 vaccination campaign.
management plans. Use this input to update a statewide
distribution plan that addresses vaccine
storage, transportation, resource needs,
Point of Dispensing (POD) site mobilization,
and public communication strategies.
• Establish a working group to refine the
plan, outline an implementation strategy,
and conduct regular exercises to test its
effectiveness.
• Collaborate with trusted local partners who
bring community-specific knowledge and
existing relationships from the COVID-19
196
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
vaccination effort to improve outreach
and distribution.
4.5.1 Mass Fatality management Update, expand, train, and exercise the Cal OES
Fatality planning lacked California Coroners’ Mutual Aid Plan and its
Planning sufficient provisions to supplement, the California Mass Fatality
address infectious Management Guide.
diseases and other • Include a pandemic-specific fatality
incidents with statewide management section tailored for infectious
impacts. disease outbreaks.
• Meet with response partners at the local
and state level to discuss best practices
and lessons learned from fatality
management during the COVID-19
response.
• Engage stakeholders from various sectors
to provide input and COVID-19 related
insights during the plan development.
• Exercise the plan with jurisdictions to
include agencies that would respond to a
local, regional, and statewide fatality
management incident.
• Conduct regular training sessions and
exercises to familiarize state and local
response teams with the updated plan.
197
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
5.1.1 The lack of critical Maintain a state-level strategic stockpile and CDPH, DGS, and
Government resources hampered conduct routine assessments to identify gaps in Cal OES
Resources the effectiveness of the critical supplies or scarce resources.
state's response during • Partner with vendors to secure essential
the initial pandemic supplies during shortages, ensuring
phase. compliance with procurement regulations.
• Conduct routine quality control checks to
verify that supplies meet deployment
standards.
5.1.4 Local agencies faced Continue to develop and unify the framework Cal OES and CDPH
Resource challenges navigating across the separate ordering systems for
Management the state’s multiple Emergency Management, Medical and Health,
System resource request Schools, Fire, and Law.
procedures. • Develop and distribute standardized
guidelines offering clear, actionable steps
for all stakeholders.
• Provide ongoing training for local agencies
to effectively use the centralized system.
• Implement features such as automated
detection of duplicate requests to
streamline processes and minimize delays.
5.2.1 Resource inventory Establish and maintain dedicated, scalable DGS
Warehouse management and warehouse operations facilities to address
Management distribution efforts resource management challenges.
revealed a need for • Invest in scalable, dedicated warehouse
acquiring a larger facilities strategically located across the
198
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
warehouse facility. state, supported by regular space
utilization assessments.
• Establish agreements with state agencies
to share warehouse space, enabling cost-
sharing and resource optimization.
• Formalize MOU/MOAs with logistics
providers like UPS and FedEx to maintain
surge capacity during emergencies.
• Conduct regular assessments and exercises
to refine warehouse operations and ensure
readiness for future emergencies.
6.1.2 The Pandemic Implement fraud detection and prevention EDD
Individual Unemployment measures during the application stage to
Relief Assistance program mitigate risks in future programs.
encountered $20 billion • Integrate advanced fraud detection
in fraudulent activities. systems by employing real-time identity
verification technologies and behavioral
analytics to identify and flag suspicious
activity during the application process.
• Collaborate with cybersecurity specialists,
fraud detection experts, and law
enforcement agencies to design robust
fraud prevention frameworks.
• Conduct systematic auditing schedules to
monitor program integrity, assess
199
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
vulnerabilities, and respond to emerging
threats.
• Develop educational campaigns to raise
public awareness about fraud risks,
prevention measures, and reporting
mechanisms.
6.1.3 Business Statewide closures, Strengthen support for small businesses by GO-Biz
Relief compounded by creating contingency plans for closures and
financial disparities, targeted financial relief programs.
disproportionately • Create tailored financial assistance
impacted small programs specifically designed for small
businesses and businesses most affected by statewide
perpetuated their closures, with streamlined application
challenges. processes to improve accessibility.
• Establish technical support resources or
online platforms to provide technical
assistance and guidance to businesses
during closures.
• Introduce tax incentives or relief programs
to help small businesses invest in
technology upgrades, safety measures,
and online infrastructure.
• Create accessible training and education
programs, including workshops, to equip
business owners with tools and strategies to
adapt during emergencies.
200
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
6.2.2 Project Some local Develop a plan to update Project Roomkey by CDSS
Roomkey governments faced integrating lessons learned.
challenges securing • Assess homelessness at the county level to
accommodations to determine jurisdiction-specific needs and
support Project tailor resource allocation accordingly.
Roomkey. • Gather feedback from local agencies and
stakeholders to understand their
experiences with Project Roomkey.
• Establish clear contractual agreements
with hotel operators, addressing liability
and insurance concerns to streamline
future partnerships
• Monitor and evaluate the program's
effectiveness, focusing on serving
populations disproportionately affected by
homelessness and identifying at-risk
individuals.
• Partner with private and public entities to
create additional funding streams and
resources, ensuring the program’s long-
term viability.
6.3.1 Great The Great Plates Provide implementation guidance and Cal OES
Plates Delivered program was supporting documentation, including
Delivered announced before its reimbursement information, to local governments
mission or objectives prior to the public announcement of a program.
were communicated to
201
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
the counties. •Coordinate a conference call with
Operational Areas to discuss upcoming
programs, policies, and initiatives, including
reimbursement procedures.
• Provide a document addressing frequently
asked questions to help jurisdictions
communicate effectively with their
communities.
7.1.2 Inmate Insufficient inmate Regularly update and enforce established CDCR
Transfers transfer protocols and protocols for inmate transfers and infection
poor infection control control during public health emergencies.
measures contributed to • Align transfer protocols with current public
significant outbreaks health guidelines and limit transfers to
among staff and essential cases.
inmates. • Conduct health screenings before
transfers, quarantine transferred inmates in
separate units, and restrict movement
between housing blocks for both inmates
and staff.
• Incorporate lessons from past outbreaks
into staff training and emergency plans to
address operational challenges.
• Conduct drills and audits to test
compliance with protocols and identify
areas for improvement.
202
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
7.1.3 Infrastructure and Modernize state correctional facilities and CDCR
Correctional operational limitations address any deficiencies in its infrastructure,
Facilities at San Quentin focusing on redesigning communal areas,
Outbreak contributed to an improving ventilation systems, and enhancing
outbreak. overall facilities.
• Develop a capacity management plan to
ensure the prison population aligns with its
design capacity, allowing effective social
distancing.
• Upgrade the ventilation systems to meet
modern health and safety standards,
reducing the risk of airborne virus
transmission.
• Enhance medical facilities to
accommodate mass testing, isolation, and
treatment requirements.
• Redesign communal areas to reduce
crowding and improve infection
prevention measures.
7.2.1 Changing guidance led Develop a clear, consistent communication plan CDCR
Guidance to low compliance to promote compliance with protective
among staff and measures.
inmates. • Provide regular, clear communication with
staff and inmates to reinforce the
importance of protective measures.
203
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
• Implement comprehensive educational
programs to address the significance of
health measures and dispel
misconceptions.
• Establish an open forum for dialogue
between CDCR leadership and staff to
address concerns and clarify directives.
• Support correctional staff with tools and
training to effectively enforce compliance
with health protocols.
7.2.2 Changes in the state's Develop a comprehensive communications plan CDCR
Visitation guidance delayed the to support timely updates on visitation policy
implementation of changes.
updated protocols, • Include transparent mechanisms for
particularly the reporting the reasoning behind visitation
cancellation of in- policy changes to inmates and families.
person visitation, which • Establish regularly scheduled meetings with
prevented family advocacy groups like the SIFC for
members from seeing consistent messaging and information
loved ones in sharing.
correctional facilities. • Provide correctional staff with training and
resources to support the implementation of
visitation policies and effective
communication strategies.
204
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
7.2.3 The demand for testing Establish standardized protocols for testing CDCR and CDPH
Corrections revealed a lack of procedures across all correctional facilities to
Testing Task adequate strategy to achieve consistency and efficiency. Include
Force address the unique guidelines for setting up testing sites, managing
needs of correctional physical space, and handling testing equipment.
environments. • Tailor testing and quarantine procedures to
accommodate different facility sizes,
layouts, and inmate populations.
• Enhance communication channels
between state agencies and correctional
facilities to improve coordination and
resource allocation.
• Develop strategies to manage inmate
relocations during outbreaks, maintaining
testing and quarantine measures
throughout the process.
8.1.1 Schools There were multiple task Establish policy and procedures to align Task Force CDE and Cal OES
Task Force forces for Education, objectives to achieve consistent results.
and Cabinet- creating challenges in • Develop a plan to regularly align
Level implementing directives. objectives and responsibilities among task
Education forces with overlapping priorities.
Task Force • Organize joint planning sessions involving
members from all relevant task forces to
facilitate comprehensive policy creation.
• Implement regular communication
mechanisms between task forces to
205
COVID-19 After Action Report
Corrective Action Plan
CHAPTER FINDING RECOMMENDED CORRECTIVE ACTION RESPONSIBLE
ORGANIZATION
enhance information sharing and
coordination.
• Actively involve educators and school
representatives in policy discussions to
ensure practical and actionable strategies.
8.2.5 Schools The pandemic's initial Develop a statewide framework to improve CDE and CDPH
Testing Task phases revealed coordination, communication, and operational
Force significant challenges in consistency for school testing efforts during
coordinating and emergencies.
communicating school • Establish standardized reporting structures,
testing operations. workflows, and protocols for schools to
follow during testing operations.
• Create a centralized platform for real-time
communication to provide schools with
timely updates on testing protocols and
resources.
• Conduct regular training and exercises to
improve collaboration and readiness
among schools, state agencies, and other
key stakeholders.
• Streamline the process for developing and
approving guidance to minimize delays
and provide schools with accurate and
timely information.
206
File and source
- File
- caloes-covid-after-action-report-2026.pdf
- Size
- 5,543,305 bytes
- SHA-256
- 5d283d6589095b413df73120a9d0dd878b4ba3abea18c904208508860ec3eaa2
- Original
- www.caloes.ca.gov