The 132-page independent report, commissioned by the board and completed by the McChrystal Group, did not identify a "single point of failure" in the county's efforts to warn and evacuate residents as the Eaton and Palisades fires broke out Jan. 7.
Instead, it found a series of weaknesses, such as "outdated policies, inconsistent practices and communications vulnerabilities." According to the report, those factors hampered the effectiveness of the county's response to the fires.
The report noted that the hurricane-force winds that grounded firefighting aircraft and caused power outages also played a role.
"While frontline responders acted decisively and, in many cases, heroically, in the face of extraordinary conditions, the events underscored the need for clearer policies, stronger training, integrated tools, and improved public communication," the report said.
It also leaves questions as to why thousands of residents in west Altadena were not given evacuation orders until hours after flames had already been reported in the area.
After-action report on LA County January wildfires finds 'series of weaknesses'
Meanwhile, the group Altadenans for Accountability said the report "falls far short of unearthing the truth of what happened that night." The group is now asking California's Attorney General Rob Bonta to launch an investigation.
"Los Angeles County promised the report would provide a clear, fact-based review of how alerts, warnings, and evacuations were handled," read a statement released by Shawna Dawson Beer, an Altadena resident who lost her home in the fire. "Instead, the McChrystal Group's After-Action Report is a carefully, conveniently worded PR spin, tip-toeing around County missteps, assigning responsibility nowhere in particular, and worse, pointing fingers at fire victims. The report confirms what we already knew - there was no plan."
L.A. County's top elected officials addressed the report's findings last week.
"This McChrystal Group report highlights the fact that we are not prepared if, God forbid, we have another emergency like this," said L.A. County District 5 Supervisor Kathryn Barger.
During the fires, there were numerous complaints from impacted residents in the Eaton and Palisades fire zones either about not getting any alerts or too many alerts that included areas not actually impacted by the fires.
Eighteen of the 19 people killed in the Eaton Fire died on Altadena's westside, which is several miles away from where the fire began.
Why evacuation orders were delayed for west Altadena, according to the report, could not be blamed on one individual point of failure, but instead, rests in part on interagency cooperation issues.
"Outdated and inconsistent policies, protocols and standard operating procedures created ambiguity around evacuation authority and responsibilities. In many cases, decision-making roles were unclear..." the report reads.
In addition, the report calls for improved public communications, clearer policies and stronger training.
L.A. County Fire Chief Anthony Marrone said changes and improvements are already underway, but he also points out the unprecedented weather conditions that fueled the fire.
"We are going to be better next time, however, this was hurricane-force winds that unfortunately had an associated fire. We will never have enough firefighters to have a truck in front of each person's house," Marone said.
This was just the first of several after-action reports ordered by the county.
The report focuses on the actions of the county and does not include the city of Los Angeles, where there was a controversy over Mayor Karen Bass and then-L.A. Fire Chief Kristin Crowley's response during the fires.
According to the report, city agencies declined interviews for the county report.
The January wildfires killed 31 people and destroyed more than 16,000 properties in Altadena and the Pacific Palisades, along with parts of L.A., Pasadena, Sierra Madre and Malibu.