Senior Living Facility Managers Went Home as Eaton Fire Approached, State Probe Shows
Los Angeles Times
(TNS)
They were forgotten amid the frantic evacuation of two senior care facilities, according to state investigators, leaving the elderly women in immediate danger as the smoke and flames of the Eaton fire drew closer.
In two reports published recently by the California Department of Social Services, investigators describe the harrowing circumstances of three women who were left behind in the assisted living facilities during the deadly Jan. 7 fire.
While the women were ultimately rescued, state investigators cited both facilities for troubling lapses in care and ordered the homes to increase their emergency planning and training. Both senior care facilities have appealed the findings.
The investigations — which were triggered partly by reporting from The Times — have raised further questions about how officials prepared for and responded to the deadly firestorm, particularly with respect to elderly and disabled evacuees.
Laura Mosqueda, a professor of family medicine and geriatrics at USC's Keck School of Medicine, said the state's findings "demonstrate many of the problems" that senior care advocates have long called on officials to address.
"Absolutely it was chaotic because of the fires, and absolutely [assisted-living facilities] have a responsibility to have emergency plans and competent leadership who can follow through," Mosqueda said. "To evacuate and not have a complete list and know you've gotten everybody out … is not OK."
Nineteen people died in the Eaton fire, 18 of them in west Altadena, where county officials failed to issue prompt alerts about the growing threat. None, however, were residents of a senior care facility.
At the MonteCedro assisted living facility — located in a section of west Altadena where county officials sent out the latest evacuation alerts — the majority of staff members working the night of the fire had never been trained in emergency procedures, according to the state's recently published report.
Even as the winds worsened and flames spread west, "most administrative personnel and management left the facility and went home," even though they were the only group that had received emergency training, the report said.
The facility's executive director, who "was responsible for putting the emergency procedures into action," did not inform any on-site staff of the relevant procedures before leaving around 10:30 p.m., the state found.
"The individuals that had specific assigned emergency duties were not present in the facility and did not return to the facility until after 5 a.m. on the following day," the report said. "No additional instructions were given and no arrangements were made to bring additional qualified staff who had knowledge of the facility evacuation procedures."
The facility's disaster protocols instruct the executive director to call up additional staff to help with evacuations using an "emergency recall list," but investigators were told that no such list existed, according to the report.
Still, staff began evacuations around 5 a.m. on Jan. 8, with the support of the Sheriff's Department. Almost 200 residents were taken by bus to the Pasadena Convention Center over the following two hours. After conducting a roll call at the evacuation center, facility staff realized that two residents were unaccounted for and alerted the Sheriff's Department, the report said.
But it would be another two hours before deputies returned to search the building, where they found the two elderly women. One of them, who was 100, was on the third floor and roaming the dark, empty hallways with a walker when she was discovered. At the time, flames were visible out the windows.
"The two residents were left behind due to the facility's failure to follow facility emergency evacuation procedures," the report found.
James Rothrock, chief executive of Episcopal Communities & Services, which runs MonteCedro, didn't dispute that the women were left behind, but he did question several of the findings in the report. In a prepared statement, Rothrock asserted that all the staff at MonteCedro were trained in emergency procedures and said the evacuation process was "led and controlled by the L.A. County Fire and Sheriff's Department."
MonteCedro has appealed the state's findings, which remain under review.
Rothrock said facility staff have since taken "immediate steps to reinforce and strengthen our emergency-preparedness protocols," including enhanced training, and that they "take all regulatory findings seriously."
The other facility that state officials probed was The Terraces at Park Marino, a Pasadena assisted-living facility near the Eaton fire's origin. The home was forced to quickly evacuate the evening of Jan. 7, amid raining embers and approaching flames. Harrowing footage captured seniors fleeing in nightgowns, as others were pushed down the street in wheelchairs and hospital beds.
DSS officials, who license and oversee senior-care facilities, also issued The Terraces a citation after finding "that at least one resident was left in the room and had to be evacuated by the Fire Department," posing "an immediate risk to the persons in care."
The DSS report cited no other procedural missteps by The Terraces staff but said a resident on the third floor was evacuated only after the resident's "responsible party" called police, who relayed the woman's location to fire officials on site.
Pasadena Fire Capt. Trey Sorensen, who oversaw evacuations from The Terraces and other nearby senior homes, described in a podcast interview the life-and-death circumstances they faced during that evacuation.
While he emphasized that The Terraces staff did a great job that night, he explained in the interview that it was after staff reported everyone was out that he got a call about a wheelchair-user still in room 326.
"That person had called a family member, the family member called dispatch, dispatch let the command post know," Sorensen said on the podcast.
He said he sent his fire crews up to rescue her, even as the building was catching fire, and they only narrowly escaped.
The senior facility was destroyed in the blaze.
The DSS report did not clarify allegations that a second senior was also left behind on the third floor and eventually rescued by her son. The Times reported on the son's concerns in February, after he said he ran into an empty building to bring his 97-year-old mom to safety. It would be hours before facility staff called him to try to confirm her location, he said.
Those allegations initially launched the investigation into The Terraces.
Still, the recent report determined that The Terraces at Park Marino staff violated a mandate that residents have proper care and supervision when it left at least one resident behind, posing "an immediate risk to the persons in care."
Officials from The Terraces have disputed many of the state investigators' findings, both substantively and procedurally.
In its appeal, which the facility shared with The Times, officials said the investigation "overlooked" that staff were told by firefighters not to reenter the facility and that it was facility staff who informed fire officials of the resident that firefighters rescued.
"The Terraces had already informed [ Pasadena Fire Department] directly, on scene, that [the resident in 326] still required evacuation," the appeal said. "The Terraces at Park Marino not only complied with its legal obligations, it executed its evacuation plan effectively under extreme circumstance."
Officials with The Terraces also questioned why DSS released a report on their evacuation in May, then rescinded it. That first report found the allegation that a resident was left behind and rescued by her son to be unsubstantiated, due to lack of evidence. (Unsubstantiated is a different finding from unfounded).
The initial report didn't mention the resident rescued by firefighters however. DSS officials said the new report "supersedes" prior findings.
Officials with The Terraces this week called the removal of the first report improper and demanded that the initial report be republished. They also requested separate investigations into what happened to the two third-floor residents during the evacuation. Adam Khalifa, president and chief executive of facility, called the initial complaint "false allegations."
"The record is clear: our team worked in concert with the first responders to perform a mass evacuation under very difficult circumstances," Khalifa said in a prepared statement.
DSS cited The Terraces for violating the California Code of Regulations related to the personal rights of residents, and tasked the facility with updating its emergency disaster procedures. The facility plans to rebuild and reopen, a spokesperson for the facility said.
MonteCedro was cited for violating a California Health and Safety code that requires emergency plans and was ordered to provide "information on subsequent resident and staff training in regards to emergency response protocols." It survived the fire and has reopened; the executive director has since retired.
DSS spokesperson Jason Montiel said the appeals remain under review, but that facility staff at The Terraces "has been compliant and has corrected the deficiency." He said that MonteCedro had submitted its required Plan of Correction.
While elder-care advocates and relatives of those left behind have called for systemic change to ensure that such mistakes don't happen again, some worry the state findings fall short.
Mosqueda said the report findings failed to reflect the "egregious fashion" in which the seniors were exposed to danger. They also don't provide continued oversight going forward, she said.
Others are hopeful that changes have been made.
John Ward, the son of one of the women who was left behind at MonteCedro, said the report confirmed that mistakes were made that night, but he can't let it overshadow the positive community where his mom lives day-in and day-out.
"The love and care they give for the people there is just fantastic," Ward said. "They screwed up, it was a bad day for them; they didn't follow protocol and they should have. ... Other than that, they're great. ...Let's hope that they've learned."
This story originally appeared in Los Angeles Times.
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