USA – State regulators moved to revoke the licenses of two Santa Rosa senior housing facilities Thursday after finding that employees abandoned dozens of elderly and disabled residents during a confused and frantic evacuation amid the deadly Tubbs Fire last year.
Investigators with the California Department of Social Services concluded that the staffers at the Varenna and Villa Capri apartments were untrained and ill-equipped to handle evacuations, and that supervisors in both facilities left residents alone at the peak of the crisis.
Two dozen residents of Villa Capri would have died in the fire if not for the actions of family members and emergency personnel to get them out before the building went up in flames, according to a complaint filed by the department. It cites the licensed operator of the facilities, Oakmont Senior Living, as well as its management group and the executive directors of the centers, Deborah Smith and Nathan Condie.
The licenses will be revoked in 15 days unless an appeal is filed requesting a hearing before an administrative law judge.
“Based on evidence gathered during the investigations and the statements of witnesses, the department has determined that Oakmont Senior Living failed to protect the health and safety of residents at Varenna and Villa Capri,” Michael Weston, the spokesman for the California Department of Social Services, wrote in a statement. “The Department served Oakmont Senior Living with legal notice to revoke the licenses of Varenna and Villa Capri and to exclude the administrators of both facilities for life.”
Oakmont representatives denied the allegations in a statement Thursday, saying “all 418 residents were safely evacuated” and thanking families, neighbors and emergency personnel for their help.
“The night of the Tubbs fire, we voluntarily began evacuating residents after we were repeatedly unable to reach emergency authorities on clogged 911 phone lines. We never received an official evacuation order from emergency authorities,” the statement said. “Our residents and their safety have been, and always will be, our first priority.”
Oakmont officials said earlier this year that emergency personnel prevented staff from returning to the buildings to evacuate the rest of the residents.
None of the residents of the two high-end assisted-living facilities died in the fire, but the complaint describes confusion, inattention and breakdowns in communication among the managers as the fire crackled toward the building the night of Oct. 8 and early morning Oct. 9.
Smith, administrator of Villa Capri, failed to train the four staffers on duty that night in emergency and evacuation procedures, according to the complaint. They were responsible for 62 residents, 25 of whom were in the memory care unit and unable to exit the building unassisted, the report said.
The employees did not know where flashlights, batteries or keys to the facility’s vehicles were, and two of them were incapable of moving or assisting residents because they could not lift more than 10 pounds or use both hands, the document said.
One staffer searched for an hour that night, checking four rooms in the building, but could not find keys to any vehicles, the complaint said. Outside was a large bus that could have been used to evacuate all the residents, but nobody knew where to find the keys.
Sometime between 3 and 3:30 a.m., as the fire raged outside, a supervisor, who did not call 911 or notify anyone about the situation, left two untrained staffers with 30 elderly and infirm residents. They subsequently evacuated six residents in their personal vehicles, leaving 24 infirm patients alone in the building as flames approached, the complaint said.
Smith knew about the emergency at 11:30 p.m., but never made it to the facility and eventually arrived at an evacuation center at 6 a.m. the next day. The residents were saved by family members, who flagged down a police cruiser and helped their stranded relatives down from the second floor and out from behind a locked door in the lobby, the report said.
A 92-year-old woman who suffered from blindness, dementia and hearing impairments reportedly was injured with a broken hip while being rescued by a good Samaritan.
“If these family members and emergency responders had not evacuated Villa Capri residents, more than 20 residents would have perished when Villa Capri burned to the ground after all staff left the facility,” the report stated.
The situation at Varenna, where 228 residents were living, was equally chaotic, according to the report. It said Condie, the administrator, had failed to train the two health care workers and two maintenance staffers on duty that night in emergency procedures.
When Condie arrived sometime between 12:30 and 1 a.m., he was unable to articulate an evacuation plan and instead directed the staff to return the residents to their rooms, the report said. He left the facility in his car with a small number of residents at about 3:30 a.m. and did not tell the staffers where keys to a large bus owned by Varenna were located.
All the other staffers later departed, leaving the residents asleep in their rooms as the fire raged toward the facility. They were eventually evacuated by their families and friends, who reported spending hours pounding on doors, waking up and assisting residents, many using walkers and wheelchairs, to the lobby, according to the report.
When emergency responders finally arrived at 4:15 a.m., no staffers were available to identify residents or provide a list of those who were evacuated, the report said. They said they had to kick open locked doors throughout the facility to locate and alert sleeping residents.
Besides revoking the licenses of the facilities, the complaint would also ban Smith and Condie from ever again working at a care facility.
“We’re very pleased that the state of California has held Oakmont accountable and sent a very strong message that it needs to spend money on residents and not just pretty buildings,” said Kathryn Stebner, the attorney for former Villa Capri and Varenna residents, who settled a lawsuit filed on behalf of the residents Aug. 17 for an undisclosed sum.
“They said they had training and had an evacuation plan, and we found that they did not have training and they did not have an evacuation plan, and we also found that the residents were abandoned,” she said. “These people would have been dead if not for the heroic acts of family members.”
The state investigated another care facility, Fountaingrove Lodge, but no wrongdoing was found.
Peter Fimrite is a San Francisco Chronicle staff writer. Email: firstname.lastname@example.org Twitter: @pfimrite